Managing Traumatic Foot Wounds From Foreign Objects

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.

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

1. Singer AJ, Hollander JE, Quinn JV. Evaluation and management of traumatic lacerations. N Engl J Med. 1997;337(16):1142-8.

2. National Center for Health Statistics. Emergency department visits. Centers for Disease Control and Prevention (CDC). http://www.cdc.gov/nchs/fastats/ervisits.htm. Updated May 30, 2013. Accessed February 12th, 2014.

3. DeCoster TA, Miller RA. Management of traumatic foot wounds. J Am Acad Orthop Surg. 1994;2(4):226-230.

4. Owens BD, Wenke JC. Early wound irrigation improves the ability to remove bacteria. J Bone Joint Surg Am. 2007;89(8):1723-6.

5. Gustilo RB, Anderson JT. Prevention of infection in the treatment of one thousand and twenty-five open fractures of long bones: retrospective and prospective analyses. J Bone Joint Surg Am. 1976;58:453-8.

Comments

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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