Inside Insights On Treating Puncture Wounds
She says ultrasound is “very helpful” when one is dealing with a wooden foreign body. If a retained foreign body is aligned with other fibrous structures like the intrinsic muscles of the plantar foot, Dr. Judge cautions that MRI may not be able to distinguish between normal tendon and a wooden foreign body.
Dr. Keller often uses MRI to rule out osteomyelitis in the presence of a deep space abscess, saying MRI is “very sensitive and specific in these cases.” Dr. Karlock says he occasionally uses bone scans to detect potential osteomyelitis. Concurring with a previous point from Dr. Keller about the duration of puncture wounds, Dr. Karlock says he will utilize MRI or bone scan to rule out osteomyelitis for puncture wounds that are a couple of weeks old and have chronic swelling. However, he cautions clinicians to be aware of a false positive rate with these.
“A negative bone scan in a well vascularized limb can usually rule out any osseous infectious process,” adds Dr. Karlock.
If a joint space is involved or if an osseous structure has sustained concomitant insult, Dr. Judge will use nuclear medicine imaging to rule out infection. She adds that a radio-labeled leukocyte scan can identify the location and extent of any existing infection. Dr. Judge claims she has never experienced a false negative nuclear medicine WBC scan in the face of a foreign body with infection.
Q: Do you have any surgical pearls or techniques for these wounds?
A: Dr. Karlock teaches residents to extend the incision to allow full visualization of the deep structures including the flexor tendons.
Podiatrists should excise any necrotic tissue to healthy tissue, and adequately decompress any deep pockets of purulence, according to Dr. Keller. He says one should follow the path the foreign body took to see if any bone was inoculated during the initial injury. If one suspects osteomyelitis, Dr. Keller recommends a bone biopsy at the time of incision and drainage.
Dr. Karlock normally recommends copious amounts of high pressure irrigation to flush puncture wounds. For irrigations performed in the office or in the hospital, Dr. Judge advises using a 1-liter bottle of saline or sterile water. She says one should leave the whole lid intact and pierce it with an 18-gauge needle to make three very small holes that are close together. Doing so permits sterile irrigation with a moderate amount of pressure for enhanced debridement and wound irrigation, according to Dr. Judge.
Dr. Judge suggests using the metal center from a sanding disc to mark the portal of entry, noting that when taking X-rays, this is helpful in precisely marking the location of the retained foreign body. “I have never used those discs for anything else as a matter of fact,” she comments.
When taking X-rays with markers in place, Dr. Judge notes the importance of multiple projections. Since one is using planar imaging to identify the location of an object in three dimensions, she says multiple orthogonal planes can help determine the foreign body’s location, which provides a better perception of depth from the portal of entry.
Dr. Karlock will sometimes utilize intraoperative fluoroscopy to remove any retained foreign body and to utilize triangulation techniques.
Dr. Judge is a Fellow of the American College of Foot and Ankle Surgeons. She completed a three-year surgical residency program in major reconstructive surgery for the leg, foot and ankle. She is board-certified in reconstructive rearfoot and ankle surgery. She has offices in Port Clinton, Ohio and Lambertville, Mich. Dr. Judge is the Official Foot and Ankle Physician for The Jamie Farr Owens Corning LPGA Classic.
Dr. Keller is a Fellow of the American College of Foot and Ankle Surgeons. He is the Residency Director of the Benedictine Podiatric Residency Program (PM&S-36) in Kingston, N.Y. He practices at Hudson Valley Foot Associates in Kingston, N.Y.