Current Concepts In Treating Puncture Wounds

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

   The patient went to the operating room for an incision and drainage, and fibular sesamoidectomy. Upon surgical removal of the fibular sesamoid from the sesamoid apparatus, the surgeon found a wooden foreign body running parallel to the flexor hallucis longus tendon along the plantar aspect of the first metatarsal head. The piece of wood measured 3.4 cm x 0.2 cm x 0.2 cm.

   The surgeon sent a small portion of the fibular sesamoid for bone culture. The surgeon removed an ellipse of the surrounding ulceration and hypergranular tissue, and sent a specimen for pathologic examination. The surgeon performed pulsed lavage of the surgical site and loosely approximated the skin at the incision ends with sutures, leaving the central area open for drainage.

   Utilizing negative pressure wound therapy and topical wound care, the surgeon was able to quickly achieve epithelialization of the surgical site. The patient was discharged with complete healing in three weeks.

Case Study Two: Addressing Non-Healing Cat Scratches In A Patient With Diabetes

An 84-year-old woman presented with two wounds along the lateral aspect of her right leg. The wounds had been present for approximately five months and had not resolved despite prior oral antibiotics and home treatment of topical witch hazel and air drying. She denied any trauma but did recall that her pet cat had accidentally scratched her leg. Her pain level was approximately a 5 out of 10.

   Pedal pulses were palpable bilaterally. A handheld Doppler revealed a triphasic waveform. Additional observation showed hemosiderin deposition on both her legs. Small varicosities were also present. Testing with a 5.07 monofilament revealed decreased sensation to the feet. No structural osseous abnormalities were present.

   Her medical history was positive for type 1 diabetes for 14 years. She was not under treatment for any other potentially complicating conditions. Her medications included regular insulin 70/30, 40 units in the morning and Glucotrol in the evening.

   The patient denied any history of tobacco use, alcohol or intravenous drug abuse. The married woman was retired and lived at home. Upon the initial evaluation, the patient did not show any clinical signs of infection but did present with two distinctive wounds that were completely covered with black necrotic tissue.

   The physician performed debridement of necrotic tissue with a #2 bone curette to reveal ulcer bases that were characterized by mostly yellow fibrinous tissue. Cultures subsequently revealed the presence of diphtheroids.

   The physician cleaned the wounds with a topical antiseptic after obtaining cultures. The physician decided not to prescribe empiric antibiotics as there was no clinical justification for this. This remained the case after the patient continued to show progress and improvement at each visit.

   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.

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