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Three Part Question

In [patients with compound fractures of the distal phalanges] are [antibiotics] required to [prevent osteomyelitis].

Clinical Scenario

A patient presents with a fingertip injury that includes a laceration to the nail bed. The X-ray demonstrates a fracture of the distal phalanx. Should the patient receive antibiotics to prevent osteomyelitis, after appropriate wound toilet and closure?

Search Strategy

EMBASE from 1–80 to 2011 Week 08, Ovid MEDLINE 1948 to Feb Week 4 2011 with the following search strategy—
((trauma$ OR fracture$).af AND (finger OR phalanx$).af AND antibiotic$.af) limited to English language and human.

Search Outcome

One-hundred and eighty-seven papers were found, of which four were considered relevant to the three-part question.

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
Stevenson et al, 2003, UK	193 patients >16 years old with an open fracture of the distal phalanx Randomised to placebo or flucloxacillin 500mg qds for 5 days, with all receiving wound toilet and tissue repair Excluded closed subungual haematoma & fracture, but include trephined subungual haematoma & fracture Exclusion criteria were wounds >12 hours old, Hx of diabetes, oral steroid therapy, fractures cause by a bite, those on an antibiotic, allergy to penicillin	Randomised controlled trial, single blinded	Infection rate in each group (review carried out at 4 or 5 days, 14 days and 8 weeks)	Non-significant difference in infection rates as measured by a difference in proportion test between the two groups (P>0.05). 4% in placebo group, 3% in antibiotic group. 84% overall compliance rate with flucloxacillin	Strengths included a pilot study to allow an accurate power calculation, as well as analysis on an intention to treat basis
Altergott et al, 2008, USA	146 patients < 18 years old with injuries distal to DIPJ classified into damage to nailbed requiring repair, simple laceration, loss of skin or pulp, partial amputation, full amputation Patients randomized to no antibiotic or cephalexin 50mg/kg divided tds for 7 days, with all receiving wound toilet and tissue repair Exclusion criteria were wounds > 8 hours old, gross contamination, immune deficiency, diabetes, steroid therapy, oncological disorder, allergy to cephalosporins, or those on an antibiotic	Randomised trial, single blinded non inferiority	Infection rate in each group (review carried out at 7 days)	No statistical difference in infection rate between the no antibiotic group 1.45% (95% CI 0.04% - 7.81%) versus 1.52% (95% CI 0.04% - 8.16%) in the antibiotic group. Upper limit of a 1 sided 95% CI for the difference in rates was 4.9% (suggesting that the infection rate in the no antibiotic group would not exceed that of the antibiotic group by more than 4.9%).	Power calculation was a pragmatic combination of the numbers researchers expected to be able to recruit combined with a power calculation No true randomization Study terminated early due to staffing issues 11 subjects withdrew – no intention to treat analysis Infection rates too low to allow inter-group analysis
Sloan et al, 1987, UK	85 adults presenting with recent (<6 h) open fractures of distal phalanges	Controlled clinical trial comparing no antibiotics with three different antibiotic regimes	Infection rate	Three out of 10 patients who received no antibiotics developed infection compared with a total of two out of 75 patients who had received antibiotic	Small numbers. No randomisation or randomisation not described. Stopped recruiting patients to no antibiotic group as felt unethical due to high infection rate. Unblinded. Describes variable wound severity but no description of severity of injuries in each of the groups
Suprock et al, 1990, USA	91 patients with open fractures of the finger. Surgical irrigation and debridement with or without antibiotics	Controlled clinical trial	Infection rate	Four patients in each group developed infection	Quasi-randomisation technique (alternate days). No blinding

Comment(s)

The two most recent papers, Altergott et al and Stevenson et al, were of reasonable quality and neither study found that antibiotics were required to prevent infection.

The paper by Stevenson et al looked at compound fractures in adult patients. The power calculation was based on 2% overall infection rate.

The paper by Altergott et al, the only to examine a paediatric patient group, included all fingertip injuries, and consequently only 39.1% of the sample had a fracture. In addition, four patients presented with infection after the follow-up appointment, and these were not included in the results.

There has been a previous BET on this subject, Thomas et al, which discussed the first two papers listed in the above table , Sloan et al and Suprock et al. Both of these papers had significant methodological weaknesses in terms of randomisation, allocation concealment and blinding. The other papers included in the table had not been published at the time of the previous BET.

No patients included in any of the studies developed osteomyelitis, which suggests that it is an uncommon consequence of fingertip injury. The evidence also suggests that early presentation and appropriate wound management are sufficient to prevent infection.

Editor Comment

DIPJ, Distal inter-phalangeal joint.

Clinical Bottom Line

Antibiotics are not indicated if appropriate initial wound management takes place. Use of antibiotics has no significant effect on overall infection rates.

References

1. Stevenson J, McNaughton G, Riley J. The use of prophylactic flucloxacillin in treatment of open fractures of the distal phalanx within an accident and emergency department: a double-blind randomized placebo-controlled trial J Hand Surg Br 2003 28(5): 388-94.
2. Altergott C, Garcia FJ, Nager AL. Pediatric fingertip injuries – do prophylactic antibiotics alter infection rates? Pediatric Emergency Care 2008. 24(3): 148-52.
3. Sloan JP, Dove AF, Maheson M et al. Antibiotics in open fractures of the distal phalanx? J Hand Surg Br 1987 12(1): 123-4
4. Suprock MD, Hood JM, Lubahn JD. Role of antibiotics in open fractures of the finger. J Hand Surg (Am) 1990. 15(5): 761-4.
5. Thomas M, Jones S. Antibiotics and compound finger fracture. J Accid Emerg Med 2000 17:212-213.