Current Concepts In Treating Puncture Wounds

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

   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.

   Upon initial examination, the sub-first metatarsal head puncture wound on the right foot measured 1.5 cm x 1 cm x 1 cm and had a hypergranular base. The area probed to bone and had milky white purulent discharge with compression. There was no odor, no crepitation, no surrounding erythema or proximal streaking. The patient had an adequate vascular supply with easily palpable pedal pulses and a capillary refill time that was within normal limits. The patient’s white blood cell count was 8.7 at admission.

   An initial X-ray showed no visible signs of osteomyelitis or a foreign body. The MRI showed increased marrow edema of the fibular sesamoid consistent with osteomyelitis with no foreign bodies or abscesses present.

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