Current Concepts In Treating Puncture Wounds

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47
Author(s): 
Desmond Bell, DPM, CWS, and David Swain, DPM

   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.

   In cases in which infection is present, obtain wound cultures from the deepest aspect of the puncture site or resulting sinus tract. Monitor vital signs and draw labs including: a complete blood cell count (CBC) (especially to determine and monitor the trend of an elevated white blood count); Chem 7 (to monitor renal function and potential dehydration); and erythrocyte sedimentation rate (ESR) (a marker for systemic inflammation and for further trends indicating persistence, worsening or improvement). Should one suspect underlying osteomyelitis, a C-reactive protein would also be advisable.

   The hospital represents a more controlled and efficient environment to manage such cases. In severe cases, additional consultations with specialists such as infectious disease physicians, vascular surgeons or internal medicine doctors, to name a few, are recommended.

Keys To Treating Puncture Wounds

In regard to treating puncture wounds, one should start with appropriate antibiotics that are ideally based on culture and sensitivity (C&S) reports. Clinicians may pursue empirical treatment when necessary if C&S results are not yet available. Pennycook and colleagues conducted a study, which included 80 patients with puncture wounds of the foot.4 They found that of the 80 patients, none developed infection if they received oral antibiotics within the first 24 hours after injury. The study authors therefore recommended antibiotic prophylaxis for puncture wounds of the foot.

   When treating a puncture wound, assuming any foreign bodies have been extracted, one should debride the wound of all non-viable tissue and pack it open. One should not suture puncture wounds closed due to a concern of trapping bacteria into a deep structure. Provide wound care that consists of regular cleaning or flushing, packing if appropriate (based on the size and depth of wound) and use of a dressing, which will protect the site from the further introduction of bacteria from the outside environment. A dressing should also optimally control the healing environment by assisting in the removal of exudate while maintaining a slightly moist environment to promote angiogenesis.

Case Study One: When Stepping On A Wooden Skewer Leads To Cellulitis

This patient is a pleasant 59-year-old female who stepped on a large wooden skewer with her right foot. She immediately pulled the skewer out of her foot and treated the resulting puncture wound with triple antibiotic ointment and a bandage daily. The area did not heal and three months later, the foot became painful and swollen with purulent discharge. She went to the ER and was admitted for pain and cellulitis of the right foot.

   The patient’s past medical history consisted of type II diabetes, neuropathy, hypertension, hepatitis and eczema. Her past surgical history was non-contributory. The patient denied any current smoking, drinking or recreational drug abuse. However, she did have a history of tobacco and cocaine abuse.

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