How To Address Puncture Wounds
Continuing Education Course #156
I am pleased to introduce the latest article, “How To Address Puncture Wounds,” in our CE series. This series, brought to you by the North American Center for Continuing Medical Education (NACCME), consists of complimentary CE activities that qualify for one continuing education contact hour (.1 CEU). Readers will not be required to pay a processing fee for this course.
Seemingly benign puncture wounds may have potentially serious complications, including osteomyelitis, when there is delayed treatment. Accordingly, Michael Keller, DPM, and Jacob D. Fassman, DPM, detail what one should look for during an exam, discuss what imaging techniques are effective and review proper antibiotic use for such wounds. They also discuss the treatment of puncture wounds in patients with diabetes.
At the end of this article, you will find a nine-question exam. Please mark your responses on the enclosed postcard and return it to NACCME. This continuing education course will also be available on Podiatry Today’s Web site (www.podiatrytoday.com) so you can submit your responses online. I hope this CE series contributes to your clinical skills.
Jeff A. Hall
INSTRUCTIONS: Physicians may receive one continuing education contact hour (.1 CEU) by reading the article on pg. 77 and successfully answering the questions on pg. 82. Use the enclosed card provided to submit your answers or log on to www.podiatrytoday.com and respond via fax to (610) 560-0502.
Sponsored by the North American Center for Continuing Medical Education.
Plantar puncture wounds are injuries that podiatric physicians commonly encounter. Clinicians often see puncture wounds in children who have played outdoors with or without shoes.1 Many of these wounds are the result of nails, sewing needles, broken glass, wooden toothpicks, tacks, thorns and animal bites.1 Most wounds heal uneventfully.
However, a delay in treatment or inadequate treatment can lead to complications.2 The most common complications are cellulitis, deep space abscess, osteomyelitis, septic arthritis and retained foreign body granuloma.3 In managing pedal puncture wounds, the obvious goal is to prevent complications and/or limit the spread of infectious processes.
One should start with a comprehensive medical history. Be sure to ask about current medications and allergies. It is critical to ascertain the time and date of the injury, and any treatment that may have been rendered. Ascertain the type of shoe gear the patient wore (if any), the environment in which the wound occurred and the type of penetrating object.
This information can offer clues as to the type of organism that can result in secondary infection and the possibility of a retained foreign body.
Gathering information on the patient’s tetanus status is also important. Puncture wounds can be prone to Clostridium, leading to severe systemic infection. For appropriate tetanus immunization guidelines, see “A Review Of Guidelines For Tetanus Immunization.”7
What To Look For When Evaluating The Wound
Careful inspection of the wound is important. The puncture site usually exhibits signs of acute injury such as localized erythema and edema. If time has elapsed, the wound may have closed over and it can be difficult to locate the area of penetration.
The greatest failure in dealing with pedal puncture wounds is a tendency toward under-treatment due to the benign appearance of many of these wounds.2
Depth of penetration is an important factor. According to the literature, the deeper the penetration, the more likely a serious complication will occur.5 However, it is often difficult to get an accurate estimate of the true depth. Penetration into deep structures such as tendons, bursae and joint capsule may allow infectious organisms to establish themselves due to the relative avascularity of these structures. Evaluation of the patient’s motor and sensory function is important so as not to miss a lacerated tendon or nerve.
Inspection of wound edges is crucial. Clean wound edges/margins are less likely to harbor bacteria. Jagged, irregular wound margins can lead to skin necrosis due to an increase in the surface area of multiple skin apices. Not only are such wounds relatively avascular, they also have a greater potential for inoculation and infection.
Pertinent Insights On Diagnostic Imaging
Always take standard radiographs of any puncture wound. The X-rays can determine the presence of a retained foreign body or if any osseous structure has been breached. However, keep in mind that standard radiographs may be inadequate in the detection of small pieces of glass, wood or rubber. In those cases, one may need to obtain advanced imaging studies.
Researchers have shown that computerized tomography (CT) provides superior imaging in detecting wood deep in tissues.6 Magnetic resonance imaging (MRI) may be helpful, especially in detecting osteomyelitis, as MRI provides a precise anatomic location of the infection and assists the surgeon when planning surgical debridement.7 Ultrasound is a very helpful modality in detecting non-radiopaque foreign bodies and is cost-effective.
Radionuclide imaging is important and very helpful when suspecting osteomyelitis. Plain films do not detect osteomyelitis for 10 to 14 days after the establishment of bone infection. Technetium 99m methylene diphosphonate (Tc99m MDP) bone scans are very sensitive and can detect bone infection within 24 hours of the onset of infection. Be aware that Tc99m MDP has a low specificity and tagged white blood cell scans (i.e. HMPAO scans) may be more specific for localizing infection.8
One should obtain laboratory studies. A white blood cell count and comprehensive metabolic panel can be insightful in cases of suspected infectious processes. Notably, one may evaluate erythrocyte sedimentation rate (ESR), especially when osteomyelitis is present. Clinicians often use ESR to assess the treatment of patients with osteomyelitis.
What You Should Know About Osteomyelitis And Puncture Wounds
Osteomyelitis is the most severe complication secondary to a puncture wound. The incidence of osteomyelitis is associated with the location of the injury, delay in treatment and whether the patient wore footwear at the time of injury.9
Fitzgerald and Cowan have reported the incidence of puncture wounds progressing to osteomyelitis as 1.8 percent in the pediatric population.10 Houston, et al., reported that only 51 of 2,303 patients (2.2 percent) developed wound infections and only one of these 51 (2 percent) developed osteomyelitis.11 The true incidence of infection is unknown.
The course of osteomyelitis is often slow and indolent. Patients will often recall a puncture wound, which may or may not have been treated professionally. The wound often resolves. Then several days to months later, the patient develops increased pain and swelling with or without drainage from the puncture site. At this point, one should consider a diagnosis of osteomyelitis and/or retained foreign body.
A Guide To The Microbiology Of Puncture Wounds
Many forms of bacteria have been isolated in puncture wounds of the foot. The most common gram-positive organisms isolated in these wounds are Staphylococcus aureus, alpha-hemolytic Streptococci and Staphylococcus epidermidis.12 Researchers have also identified gram-negative organisms such as Escherichia coli, Proteus and Klebsiella sp.12 Pasteurella multocida has been isolated from dog and cat bites, and Eikenella corrodens has been isolated from human bite wounds.13 Miscellaneous organisms that have been isolated from puncture wounds occurring in brackish water include Aeromonas hydrophilia and Mycobacterium marinum.14
Pseudomonas is the most common organism responsible for osteomyelitis secondary to puncture wounds.15 There is a documented association between rubber soled shoes and pseudomonal osteomyelitis.15,16 When a nail or other object penetrates the shoe and then the foot, it inoculates the wound with the pseudomonal organism found on the shoe.
Treating Puncture Wounds In Patients With Diabetes
When a patient with diabetes presents with a puncture wound, one must consider a unique set of factors. These wounds can be limb- or life-threatening and one needs to manage these wounds aggressively. Peripheral neuropathy, immunopathy and peripheral arterial disease result in a greater risk for complications. Patients with diabetes are often unaware of the initial injury due to loss of protective sensation. Wounds may go undetected and are at greater risk for infection. Due to immunopathy, these patients may not develop systemic signs of sepsis, such as chills, fever or night sweats. Laboratory studies may also be under-representative of a severe infection.17
Patients with diabetes are also prone to polymicrobial infections such as gram-positive, gram-negative and anaerobic bacteria. Accordingly, it is recommended to choose the appropriate antibiotics as outlined below and/or consult an infectious disease specialist.
Key Tips On Treatment For Puncture Wounds
“The delay between the time of injury and the initiation of treatment is perhaps the most critical factor in determining whether or not an infection develops and the severity of complications following a puncture wound.”18
Upon the initial presentation of a pedal puncture wound, one must first perform a problem-focused history and physical exam, paying close attention to details involving the source and time lapse of injury. Furthermore, one must give special consideration to any comorbidities such as diabetes mellitus with or without neuropathy, peripheral vascular disease or other immunocompromised conditions.
During the physical examination, be sure to evaluate the size, depth and shape of the punctured foot wound. Pay close attention to the skin edges. Often, traumatic objects may leave a jagged appearance. To determine depth and possible fascial/capsular/bony involvement, use a blunt, sterile probe.2
If there is no evidence of a retained foreign body, and the wound is superficial, small and discovered in less than six hours, it is reasonable to cleanse the wound with saline (preferably with a large 20 cc syringe) and cover it with a sterile dressing (see “A Guide To The University Of Texas Puncture Wound Scoring System”).
When a puncture wound presents in the delayed setting, is deep or has significant clinical contamination, incision and drainage is recommended. If there is a retained foreign body, triangulation with fluoroscopy and/or ultrasound can be helpful. Nonetheless, one should aggressively debride all necrotic/nonviable soft tissue and bone using a high-pressure pulse lavage.18 Sharply incise jagged skin edges to decrease the chance of skin necrosis. Pack these wounds open or close them over a drain (i.e. Penrose, closed suction).
In the operating room setting, obtain deep wound and tissue cultures. If there is suspected bony involvement, obtain bone cultures to rule out osteomyelitis.
When Are Antibiotics Appropriate?
Address antibiosis and appropriately administer antibiotics when a patient sustains a traumatic puncture wound. When a patient presents early (less than six hours) with a clean, uninfected puncture wound and has no medical comorbidities, one should render clinical treatment. However, empiric antibiotics are not required. If a patient does have certain risk factors for developing infection, is seen in the delayed setting or presents with a grossly contaminated wound, one should give antibiotics.
First-generation cephalosporins such as cephalexin or cefadroxil are sufficient for most superficial puncture wounds. If the wound is grossly contaminated and/or a metallic object has penetrated the skin or shoe, then one should adjust empiric antibiotics accordingly.
In this scenario, typical anti-pseudomonal antibiotics are ciprofloxacin or levofloxacin. While ceftazadime and aztreonam are strictly intravenous anti-pseudomonal antibiotics, they work well for inpatients.
Broad-spectrum antibiotics are also recommended for the diabetic patient or a patient who has a dirty wound. Amoxicillin/clavulanic acid, trimethoprim/sulfamethoxazole or combination antibiotics, such as clindamycin and ciprofloxacin, provide appropriate bacterial coverage. If the patient requires hospital admission and an intravenous line, broad-spectrum antibiotics such as piperacillin/ tazobactam or imipenem/cilastatin are recommended.
With the emergence of resistant organisms such as methicillin-resistant Staphylococcus aureus (MRSA), vancomycin resistant Enterococcus (VRE) and multi-drug resistant Pseudomonas, one may argue that empiric antibiotics to cover such resistant organisms are warranted. In New York City, the prevalence of MRSA is an astounding 24 percent. Furthermore, community-acquired MRSA is on the rise throughout the United States.19
A large multicenter study in the New England Journal of Medicine determined that “MRSA is the most common identifiable cause of skin and soft tissue infections among patients presenting to emergency departments in 11 U.S. cities. Moreover, when antimicrobial therapy is indicated for the treatment of skin and soft tissue infections, clinicians should consider obtaining cultures and modifying empirical therapy to provide MRSA coverage.”19
Therefore, it is the senior author’s recommendation that when patients with a traumatic puncture wound present with an abscess or cellulitis, has multiple comorbidities or certain risk factors for MRSA (i.e. history of MRSA, healthcare worker who is exposed to resistant Staph, multiple hospitalizations, steroid use, etc.), it would be prudent to treat these patients empirically with anti-MRSA antibiotics.19
Currently at our institution, if a patient presents without risk factors for MRSA colonization, we do not administer routine anti-MRSA antibiotics. In time, however, our protocol may change as drug resistance patterns change. It is important to have a working relationship with infectious disease specialists in your community to ensure the best approach to handle this challenging and evolving dilemma.
Puncture wounds are common traumatic pedal injuries. Serious complications such as skin necrosis, deep abscess formation and osteomyelitis can occur. When the podiatric physician obtains a thorough history and physical examination in conjunction with the use of imaging and clinical insight, he or she can avoid most complications. Give consideration to appropriate antibiosis and surgical intervention when necessary. Remember that time is of value and to consider all risk factors when evaluating these wounds.
1. Baldwin G, Colbourne M. Puncture wounds. Pediatr Rev 20:21-23, 1999.
2. Haverstock BD, Grossman JP. Puncture wounds of the foot: evaluation and treatment. Foot Ankle Trauma 16:583-596, 1999.
3. Chudnofsky CR, Sebastian S. Special wounds: nail bed plantar puncture and cartilage. Emerg Med Clin N Am 10:801-821, 1992.
4. Fleisher GR. The management of bite wounds. N Engl J Med 340:138-140, 1999.
5. Patzakis MJ, Wilkens J, Brien WW, et al. Wound site as a predictor of complications following deep nail punctures to the foot. West J Med 150:545-547, 1989.
6. Nyska M, Pomeranz S, Porat S. The advantage of computerized tomography in locating a foreign body in the foot. J Trauma 26:93-95, 1986.
7. Lau LS, Bin G, Jaovisidua S, et al. Cost-effectiveness of magnetic resonance imaging in diagnosing Pseudomonas aeruginosa infection after a puncture wound. J Foot Ankle Surg 36:36-43, 1997.
8. Blume PA, Dey HM, Daley LJ, et al. Diagnosis of pedal osteomyelitis with Tc-99m HMPAO labeled leukocytes. J Foot Ankle Surg 36:120-126, 1997.
9. Lavery LA, Harkless LB, Ashry HR, et al. Infected puncture wounds in the adult with diabetes: risk factors for osteomyelitis. J Foot Ankle Surg 33:561-566, 1994.
10. Fitzgerald RH Jr., Cowan JD. Puncture wounds of the foot. Orthop Clin N Am 6:965-972, 1975.
11. Houston A, Roy W, Faust R. Tetanus prophylaxis in the treatment of puncture wound of patients in the deep south. J Trauma 2:439-446, 1962.
12. Joseph WS, LeFrock JL. Infections complicating puncture wounds of the foot. J Foot Surg 26:530-532, 1987.
13. Butt TS, Khan A, Ahmad MA, et al. Pasteurella multocida infectious arthritis with gout after a cat bite. J Rheumatol 24:1649-1652, 1997.
14. Joseph WS. Infections following trauma. In Handbook of Lower Extremity Infections, p. 69-74, Churchill Livingston, N.Y., 1990.
15. Fisher MC, Goldsmith JF, Gilligan PH. Sneakers as a source of Pseudomonas aeruginosa in children with osteomyelitis following puncture wounds. J Pediatr 106:607-609, 1985.
16. Saha P, Parrish CA, McMillan. Pseudomonas osteomyelitis after a plantar puncture wound through a rubber sandal. Pediatr Infect Dis 15:710-711, 1996.
17. Lavery LA, Armstrong DG, Quebedeaux TL, et al. Normal laboratory values in the face of severe infections in diabetics and non-diabetics. Am J Med 101:521-525, 1996.
18. Banks AS, Downey MS, Martin DE, et al. McGlamry’s Comprehensive Textbook of Foot and Ankle Surgery. Philadelphia: JB Lippincott, p. 1653-1658, 2001.
19. Moran GJ, Krishnadasan A, Gorwitz RJ, et al. Methicillin-resistant S. aureus infections among patients in the emergency department. N Engl J Med 355:66-673, 2006.
20. Krych SM, Lavery LA. Puncture wounds and foreign body reactions. Clin Podiatr Med Surg 7:725-731, 1990.
|CE Exam #156|
|Choose the single best answer to the following questions.
1. While most puncture wounds heal uneventfully, potential
2. When it comes to puncture wounds, jagged, irregular wound margins …
a) are relatively avascular but are less likely to harbor bacteria.
3.When it comes to X-rays of a puncture wound, they …
a) are particularly effective in detecting small pieces of wood in a wound.
4. Magnetic resonance imaging (MRI) …
a) provides superior imaging in detecting wood deep in tissues.
5. According to Fitzgerald and Cowan, the incidence of puncture wounds progressing to osteomyelitis in the pediatric
6. _______ is the most common organism responsible for osteomyelitis secondary to
a) Staphylococcus aureus
7. True or false: Due to immunopathy, diabetic patients with puncture wounds always have more advanced systemic signs of sepsis than non-diabetic patients with puncture wounds.
8. When a patient sustains a traumatic puncture wound, empiric antibiotics are not required if the patient ...
a) presents early (less than 48 hours), has a minor wound infection and no medical comorbidities.
9. What antibiotics are sufficient for most superficial puncture wounds?
a) First-generation cephalosporins such as cephalexin and cefadroxil
Instructions for Submitting Exams
Fill out the enclosed card that appears on the following page or fax the form to the NACCME at (610) 560-0502. Within 60 days, you will be advised that you have passed or failed the exam. A score of 70 percent or above will comprise a passing grade. A certificate will be awarded to participants who successfully complete the exam. Responses will be accepted up to 12 months from the publication date.