Managing Traumatic Foot Wounds From Foreign Objects

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

Case Study: When A Patient’s Foot Is Impaled By A Scooter Brake Handle

In the summer of 2013, a 27-year-old female patient presented to the emergency department after her left foot was impaled with a foreign object. The patient’s younger brother (who weighs over 200 lbs.) had an accident with his electric motorized scooter and had fallen onto the patient’s foot. The scooter hand-brake handle was sharp and jagged from previous falls, and easily penetrated the foot of the patient, who had been wearing flip-flops at the time.

   The patient presented to the emergency room complaining of intense pain to her left foot. The scooter handlebars were cut off at the site of the accident by paramedic responders. The foreign object had penetrated the foot from dorsal to plantar. Upon arrival to the emergency department, the patient had already received IV morphine for pain control, cefazolin for antibiosis and a tetanus booster shot. The patient denied any past medical history or use of medications.

   The physical exam demonstrated a patient in severe pain and distress. She rated her pain as a 10/10 even after the administration of medications. The vascular exam revealed a strong posterior tibial (PT) pulse of the left foot. The dorsalis pedis (DP) pulse was not detectable at this time due to the orientation of the foreign object and severe pedal edema. A neurological exam of the foot revealed decreased sensation to digits via light touch. We could not assess the motor function at the time due to excruciating pain.

   We obtained radiographs of the foot to rule out any fractures and assess positioning of the foreign object. Surprisingly, the radiographs did not demonstrate any osseous abnormalities. Possibility of small linear fracture of adjacent metatarsal could not be excluded.

   We scheduled the patient for emergency irrigation and debridement of the left foot with removal of the foreign body. After we removed the foreign body, an inspection of the dorsal wound revealed a healthy, palpating dorsalis pedis artery. Although the soft tissue injury was complicated, there was no vascular damage to major vessels of the foot. Noting extensor tendon injuries to the third and fourth digits, we re-approximated these tendons.

   After irrigating the wound with nine liters of sterile saline infused with bacitracin, we inspected and cleansed the wound of any remaining debris. Wound closure became a challenge due to the soft tissue defect and edema. Closing the wound to the best of our ability, we did leave an open wound measuring 2.5 cm x 3.5 cm on the dorsal distal part of the foot. We monitored the patient closely on a biweekly basis for wound care and eventually referred her to plastic surgery for graft placement.

   With the patient being young and healthy, the wound healed promptly after the skin graft application. The patient recovered all motor function to digits and is able to fully function in regular shoe gear. She did have residual numbness and tingling on the dorsum of the left foot and digits due to possible nerve damage.

In Conclusion

Traumatic wounds are a common encounter for podiatric physicians in the emergency room. One should tailor the diagnosis and treatment to individual cases. Aggressive treatment with irrigation and debridement of these wounds has proven to give the best results for the patient.

Our case demonstrated a classic traumatic wound caused by a foreign object. We provided aggressive irrigation and debridement followed by close monitoring for wound care. We also pursued a plastic surgery consult to obtain best result for our patient. In this type of case, it is very important to intervene quickly, assess injury for any complication and utilize consults for the patient’s best outcome.

   Dr. Palmieri is a podiatry resident at the Captain James A. Lovell Federal Health Care Center in North Chicago, IL

   Dr. Geary is a podiatry attending affiliated with the Captain James A. Lovell Federal Health Care Center in North Chicago, IL.

References

Comments

dinovisjp's picture

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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