Current Concepts In Treating Puncture Wounds

Desmond Bell, DPM, CWS, and David Swain, DPM

Although puncture wounds can initially be little more than an annoyance to patients, some wounds in certain populations can evolve into limb- and/or life-threatening complications. Accordingly, these authors review possible etiologies, discuss keys to diagnosis and treatment, and provide intriguing case studies.

“Puncture wound” is truly a wastebasket term used to describe what often becomes the medical equivalent of treating a wastebasket. The inoculation of a patient by a foreign body, thus introducing any number of bacterial organisms or spores, can create a medical scenario ranging from the simple to the life threatening.

   Attempts at self treatment by patients can result in success. However, conditions such as diabetes, peripheral neuropathy and peripheral vascular disease often reduce the chance of a favorable outcome when patients with these afflictions take matters into their own hands. To a compromised person, virtually any sharp or even dull object represents a potential threat of a puncture wound, especially when the portal of entry to the body occurs through the skin on the plantar surface of the foot.

   By the time many patients seek treatment for a puncture wound, they are either motivated by not remembering when they had their last tetanus shot, by pain or by an infection that has not responded to self treatment.

   Basic treatment options have long been established for the acute puncture wound turning bad. However, what do you do when the not so obvious injury presents itself and precious time is slipping away?

Assessing Possible Causes Of Puncture Wounds And Infection

All medical providers share a common bond that includes an ever expanding volume of cases. Just when we think we have seen it all, something comes along to remind us that we have not. No doubt, just about every practicing podiatrist has treated someone with a puncture wound of the foot.

   Another part of the equation is what caused the puncture wound. Puncture wounds are not limited to the unexpected introduction of a foreign body. Other mechanisms that can result in a puncture wound are infection from intravenous drug use, tattoos, multiple skin piercing and bites from animals
or humans.

   Objects that we remove from our patients’ shoes can often leave us questioning patients, shaking our heads in disbelief and doubting our own senses. Nails, splinters, toothpicks, glass, apple seed, a portion of a cat’s claw, needles (sewing and hypodermic), coins, a hair clipper, a golf ball and a wallet are just some of the objects that have resulted in puncture wounds or that we removed from patients’ shoes in our practice.

   The bacterial organism typically associated with puncture wounds is Clostridium tetani, which causes tetanus. Clostridium tetani occurs in soil and feces. Therefore, one should always consider this organism when a patient presents with a plantar puncture wound. Tetanus is a neurological condition, which results in painful muscle contractions, especially of the neck and jaw. Fortunately, thanks to the tetanus vaccine and overall hygiene, the instances of tetanus are rare in the United States and developed countries. However, researchers have estimated over 1 million cases worldwide annually, mostly concentrated in underdeveloped nations. Many cases in these lands occur in newborns with people utilizing unhygienic umbilical cord practices.1,2

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