Managing Traumatic Foot Wounds From Foreign Objects

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Author(s): 
Vincenzo Palmieri, DPM, and Steven Geary, DPM

Traumatic foot wounds via foreign objects are a common encounter in the emergency room for physicians. These authors review a case study of a 27-year-old female patient, who suffered a puncture wound to the foot from a foreign metallic object.

Physicians frequently see acute traumatic foot wounds in the emergency room. Reportedly more than 12 million traumatic wounds are treated in the emergency department every year.1 Puncture or impalement injuries are common. In 1999, there were 8.2 million emergency department visits for open wounds in the United States.2

   During the initial patient evaluation, the clinician should inspect the wound for foreign objects, taking wound size into consideration. Limb perfusion and neurovascular status of the foot are critical evaluation points. One should also check for edema, erythema, calor or the presence of an infectious process.

   Early intervention and close follow-up of soft tissue wounds are key components for prompt recovery and optimal healing. For major trauma wounds, the treatment is early aggressive debridement, copious irrigation and skeletal stabilization with early coverage of skin defects.3 Owens and Wenke demonstrated that earlier irrigation results in a significant decrease in bacterial colonization as well as a decrease in infection rates.4

   Local and systemic antibiotics are adjunctive to debridement to prevent infection.3 Prompt recognition and release of compartment syndrome of the foot are extremely important.3 Close observation is appropriate for traumatic wounds that appear minor on initial evaluation.3

   One should tailor the management of soft tissue injuries to the individual patient case. Multiple classification systems and treatment guidelines exist to help manage these emergency situations. The most common classification is from Gustilo and Anderson.5 Although this classification system is geared to open fracture treatment, many physicians use it to assess complicated traumatic wounds that may or may not involve an underlying fracture.

   In the classification by Gustilo and Anderson, a type 1 open fracture involves a clean skin wound less than 1 cm and a simple fracture pattern. A type 2 open fracture involves a skin wound greater than 1 cm, soft tissue damage that is not extensive, no flaps or avulsions, and a simple fracture pattern.5

   Type 3 open fractures can involve one of the following:

• a high energy injury involving extensive soft tissue damage;
• a multi-fragmentary fracture, segmental fractures or bone loss irrespective of the size of the skin wound;
• severe crush injuries;
• vascular injury requiring repair; this should be and/or
• severe contamination including farmyard injuries.5

   The use of prophylactic antibiotics is not recommended but one should address this on an individual basis. When it comes to local and systemic antibiotic coverage, clinicians should consider the degree of wound contamination, the presence of foreign bodies or contaminating objects, and wound severity. The goal of treatment in these traumatic wounds revolves around decreasing the risk of infection.

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dinovisjpsays: April 7, 2014 at 12:15 pm

A recent E.D. case of a dorsal penetrating wound with a previously used curved filleting knife through a dirt work boot of a kitchen worker comes to mind. The knife missed penetrating through the plantar skin by simply running out of kinetic energy. The patient pulled the knife out immediately. No fractures, no metal noted on X-ray.

In a review of this interesting article, several questions come to mind:

1) Were deep wound cultures taken intra-operatively especially in light of discontinuation of IV antibiotics after initial dosing?

2) Was acute compartment syndrome and release a consideration in light of pain severity and significant edema?

3) Was the tourniquet released prior to closure to assess for active bleeding and was deep soft tissue muscle appearance noted in the operative report?

Clinical Interest Note: I now use non-latex fenestrated penrose drains when needed due to a case of significant postoperative pain and swelling (with negative intra-op and repeat cultures from imbedded foreign body puncture) resulting in an extended stay (to await repeat culture results). Prior history of latex allergy was negative. Patient felt significant relief several hours after pulling the drain.

Thank you.

Jim DiNovis DPM

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