Current Concepts In Treating Puncture Wounds

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

   Pseudomonas aeruginosa is another commonly found bacterial organism associated with puncture wounds, especially in intravenous drug users. Although most puncture wounds do not progress to osteomyelitis, the majority of cases that do are attributed to Pseudomonas. This is particularly true in children who present with pedal puncture wounds.3,4

   Methicillin resistant Staph aureus (MRSA) is seemingly everywhere and should be an immediate consideration as a potential factor in all non-healing ulcers and puncture wounds as well.

   Puncture wounds occurring in a marine environment can pose unique issues. Organisms such as Vibrio species, Aeromonas hydrophila or Mycobacterium marinum are potential sources of infection.

Essential Pointers On Making A Diagnosis

Understanding the potential danger of a puncture wound is the first step toward treatment. Clinicians would subsequently pursue a thorough history and physical to facilitate proper diagnosis.

   Determining the circumstances of the puncture wound through focused interviewing of the patient can provide critical time saving information. Here are some key questions to ask.
• When and where did the injury occur?
• Was the patient wearing shoes at the time?
• Did the patient remove any debris or foreign body from the site?
• Are clinical signs of infection present?
• When was the patient’s last tetanus vaccination or booster?
• Regarding the location, is bone in close proximity to the puncture site or is a sinus track extending to deeper structures, including bone?
• What type of object did the patient observe or suspect in causing the puncture? This is particularly important in determining which diagnostic test to order, specifically whether an X-ray, ultrasound or magnetic resonance image (MRI) will be best suited to locate any suspected remnants of debris or a foreign body.

   When one suspects a metal object, a plain film should suffice, especially when significant depth or proximity to bone is of great clinical concern. If an office excision is not feasible, a C-arm fluoroscope is extremely helpful in an operating room setting. The C-arm allows for a more three-dimensional approach at retrieval whereas a plain film only allows a two-dimensional approach. The C-arm not only helps in retrieval, it can ultimately minimize further soft tissue trauma during the retrieval process.

   The availability of a portable diagnostic ultrasound unit in an office setting could also be useful in determining location and if soft tissue irregularities are present.

   In a more severe situation or when the suspected foreign body is not metallic, clinicians should utilize MRI. The MRI provides the capability to identify not only the object but also whether an abscess may be present. In extreme cases, MRI may reveal marrow edema within an adjacent bone, suggestive of osteomyelitis.

   When patients present with clinical suspicion of infection and diabetes is an underlying condition, hospital admission is strongly recommended. Patients with diabetes can reveal a subclinical presentation and then erupt into a full septic episode if left untreated due to their inherently immunocompromised condition.

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