Current Concepts In Treating Puncture Wounds

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

   The ulcers at the time of the initial visit measured approximately 0.9 cm x 0.7 cm x 0.3 cm and 0.7 cm x 0.5 cm x 0.3 cm respectively.

   The primary dressing consisted of hydrogel covered with Vaseline impregnated gauze and an absorbent foam pad. Eventually, Fibracol was part of the dressing protocol.

   Due to the presence of varicosities and some localized edema, the physician utilized mild compression in the form of an Unna boot with an elastic bandage covering.

   At the time of the 12th dressing change, during debridement of the more proximal of the two wounds, the physician noted that the small bone curette began “clinking” upon a newly discovered hard area within the wound. Using a forceps, the physician extracted a 1 mm, distinctively curved, sharp, off-white hard object, which was consistent with the distal end of a cat’s claw. A pathologist determined the composition of this foreign object.

   At the time of the 14th visit, the patient received an application of Apligraf (Organogenesis). The patient continued to make progress with twice a week compression dressing changes. The wounds resolved. The patient was discharged approximately four months after the first encounter and nearly nine months from the time of onset. The more proximal site where the surgeon removed the claw remnant resolved after the other site and no further complications occurred during the course of treatment.

In Conclusion

Most puncture wounds do not cause significant long-term problems and typically heal without complication.

   Patients who seek treatment do so for precautionary reasons, such as seeking a tetanus booster shot or when worsening of the condition becomes apparent.

   In patients who have a true infection, aggressive treatment must occur or the risk of further limb- or life-threatening complications may ensue. Treatment includes aggressive debridement, excision of any foreign bodies and proper antibiotic selection based on deep culture results. Medical management is also critical to monitor for trending or progression to sepsis.

   One should treat patients with diabetes and children who present with puncture wounds in a more emergent fashion as advanced infections in these populations may have a significant incidence of accompanying osteomyelitis.

   Proper wound care is also an important aspect of managing these patients in order to prevent re-infection and ensure efficient and optimal healing.

   Dr. Bell is a board certified wound specialist of the American Academy of Wound Management and a Fellow of the American College of Certified Wound Specialists. He is the founder of the “Save a Leg, Save a Life” Foundation, a multidisciplinary, non-profit organization dedicated to the reduction of lower extremity amputations and improving wound healing outcomes through evidence-based methodology and community outreach.

   Dr. Swain is in private practice at the Limb Salvage Institute in Jacksonville, Fla.

References

1. Okoromah CAN, Lesi AFE. Diazepam for treating tetanus. Cochrane Database of Systematic Reviews 2004, Issue 1. Art. No.: CD003954. DOI: 10.1002/14651858.CD003954.pub2
2. Available at http://www.mayoclinic.com/health/tetanus/DS00227/DSECTION=symptoms .
3. Joseph WS. Pedal puncture wound infections. In: Joseph WS, ed. Handbook of Lower Extremity Infections. Churchill Livingstone Inc., Philadelphia, pp. 69-75, 1990.
4. Pennycook A, Makower R, O’Donnell AM. Puncture wounds of the foot: Can infective complications be avoided? J R Soc Med. 1994; 87(10):581–583.

   For further reading, see “Inside Insights On Treating Puncture Wounds” in the November 2006 issue of Podiatry Today, “How To Achieve Optimal Treatment Of Puncture Wounds” in the January 2007 issue or “How To Address Puncture Wounds” in the September 2007 issue.

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