Although puncture wounds can initially be little more than an annoyance to patients, some wounds in certain populations can evolve into limb- and/or life-threatening complications. Accordingly, these authors review possible etiologies, discuss keys to diagnosis and treatment, and provide intriguing case studies.
“Puncture wound” is truly a wastebasket term used to describe what often becomes the medical equivalent of treating a wastebasket. The inoculation of a patient by a foreign body, thus introducing any number of bacterial organisms or spores, can create a medical scenario ranging from the simple to the life threatening.
Attempts at self treatment by patients can result in success. However, conditions such as diabetes, peripheral neuropathy and peripheral vascular disease often reduce the chance of a favorable outcome when patients with these afflictions take matters into their own hands. To a compromised person, virtually any sharp or even dull object represents a potential threat of a puncture wound, especially when the portal of entry to the body occurs through the skin on the plantar surface of the foot.
By the time many patients seek treatment for a puncture wound, they are either motivated by not remembering when they had their last tetanus shot, by pain or by an infection that has not responded to self treatment.
Basic treatment options have long been established for the acute puncture wound turning bad. However, what do you do when the not so obvious injury presents itself and precious time is slipping away?
Assessing Possible Causes Of Puncture Wounds And Infection
All medical providers share a common bond that includes an ever expanding volume of cases. Just when we think we have seen it all, something comes along to remind us that we have not. No doubt, just about every practicing podiatrist has treated someone with a puncture wound of the foot.
Another part of the equation is what caused the puncture wound. Puncture wounds are not limited to the unexpected introduction of a foreign body. Other mechanisms that can result in a puncture wound are infection from intravenous drug use, tattoos, multiple skin piercing and bites from animals
Objects that we remove from our patients’ shoes can often leave us questioning patients, shaking our heads in disbelief and doubting our own senses. Nails, splinters, toothpicks, glass, apple seed, a portion of a cat’s claw, needles (sewing and hypodermic), coins, a hair clipper, a golf ball and a wallet are just some of the objects that have resulted in puncture wounds or that we removed from patients’ shoes in our practice.
The bacterial organism typically associated with puncture wounds is Clostridium tetani, which causes tetanus. Clostridium tetani occurs in soil and feces. Therefore, one should always consider this organism when a patient presents with a plantar puncture wound. Tetanus is a neurological condition, which results in painful muscle contractions, especially of the neck and jaw. Fortunately, thanks to the tetanus vaccine and overall hygiene, the instances of tetanus are rare in the United States and developed countries. However, researchers have estimated over 1 million cases worldwide annually, mostly concentrated in underdeveloped nations. Many cases in these lands occur in newborns with people utilizing unhygienic umbilical cord practices.1,2
Pseudomonas aeruginosa is another commonly found bacterial organism associated with puncture wounds, especially in intravenous drug users. Although most puncture wounds do not progress to osteomyelitis, the majority of cases that do are attributed to Pseudomonas. This is particularly true in children who present with pedal puncture wounds.3,4
Methicillin resistant Staph aureus (MRSA) is seemingly everywhere and should be an immediate consideration as a potential factor in all non-healing ulcers and puncture wounds as well.
Puncture wounds occurring in a marine environment can pose unique issues. Organisms such as Vibrio species, Aeromonas hydrophila or Mycobacterium marinum are potential sources of infection.
Essential Pointers On Making A Diagnosis
Understanding the potential danger of a puncture wound is the first step toward treatment. Clinicians would subsequently pursue a thorough history and physical to facilitate proper diagnosis.
Determining the circumstances of the puncture wound through focused interviewing of the patient can provide critical time saving information. Here are some key questions to ask.
• When and where did the injury occur?
• Was the patient wearing shoes at the time?
• Did the patient remove any debris or foreign body from the site?
• Are clinical signs of infection present?
• When was the patient’s last tetanus vaccination or booster?
• Regarding the location, is bone in close proximity to the puncture site or is a sinus track extending to deeper structures, including bone?
• What type of object did the patient observe or suspect in causing the puncture? This is particularly important in determining which diagnostic test to order, specifically whether an X-ray, ultrasound or magnetic resonance image (MRI) will be best suited to locate any suspected remnants of debris or a foreign body.
When one suspects a metal object, a plain film should suffice, especially when significant depth or proximity to bone is of great clinical concern. If an office excision is not feasible, a C-arm fluoroscope is extremely helpful in an operating room setting. The C-arm allows for a more three-dimensional approach at retrieval whereas a plain film only allows a two-dimensional approach. The C-arm not only helps in retrieval, it can ultimately minimize further soft tissue trauma during the retrieval process.
The availability of a portable diagnostic ultrasound unit in an office setting could also be useful in determining location and if soft tissue irregularities are present.
In a more severe situation or when the suspected foreign body is not metallic, clinicians should utilize MRI. The MRI provides the capability to identify not only the object but also whether an abscess may be present. In extreme cases, MRI may reveal marrow edema within an adjacent bone, suggestive of osteomyelitis.
When patients present with clinical suspicion of infection and diabetes is an underlying condition, hospital admission is strongly recommended. Patients with diabetes can reveal a subclinical presentation and then erupt into a full septic episode if left untreated due to their inherently immunocompromised condition.
In cases in which infection is present, obtain wound cultures from the deepest aspect of the puncture site or resulting sinus tract. Monitor vital signs and draw labs including: a complete blood cell count (CBC) (especially to determine and monitor the trend of an elevated white blood count); Chem 7 (to monitor renal function and potential dehydration); and erythrocyte sedimentation rate (ESR) (a marker for systemic inflammation and for further trends indicating persistence, worsening or improvement). Should one suspect underlying osteomyelitis, a C-reactive protein would also be advisable.
The hospital represents a more controlled and efficient environment to manage such cases. In severe cases, additional consultations with specialists such as infectious disease physicians, vascular surgeons or internal medicine doctors, to name a few, are recommended.
Keys To Treating Puncture Wounds
In regard to treating puncture wounds, one should start with appropriate antibiotics that are ideally based on culture and sensitivity (C&S) reports. Clinicians may pursue empirical treatment when necessary if C&S results are not yet available. Pennycook and colleagues conducted a study, which included 80 patients with puncture wounds of the foot.4 They found that of the 80 patients, none developed infection if they received oral antibiotics within the first 24 hours after injury. The study authors therefore recommended antibiotic prophylaxis for puncture wounds of the foot.
When treating a puncture wound, assuming any foreign bodies have been extracted, one should debride the wound of all non-viable tissue and pack it open. One should not suture puncture wounds closed due to a concern of trapping bacteria into a deep structure. Provide wound care that consists of regular cleaning or flushing, packing if appropriate (based on the size and depth of wound) and use of a dressing, which will protect the site from the further introduction of bacteria from the outside environment. A dressing should also optimally control the healing environment by assisting in the removal of exudate while maintaining a slightly moist environment to promote angiogenesis.
Case Study One: When Stepping On A Wooden Skewer Leads To Cellulitis
This patient is a pleasant 59-year-old female who stepped on a large wooden skewer with her right foot. She immediately pulled the skewer out of her foot and treated the resulting puncture wound with triple antibiotic ointment and a bandage daily. The area did not heal and three months later, the foot became painful and swollen with purulent discharge. She went to the ER and was admitted for pain and cellulitis of the right foot.
The patient’s past medical history consisted of type II diabetes, neuropathy, hypertension, hepatitis and eczema. Her past surgical history was non-contributory. The patient denied any current smoking, drinking or recreational drug abuse. However, she did have a history of tobacco and cocaine abuse.
Upon initial examination, the sub-first metatarsal head puncture wound on the right foot measured 1.5 cm x 1 cm x 1 cm and had a hypergranular base. The area probed to bone and had milky white purulent discharge with compression. There was no odor, no crepitation, no surrounding erythema or proximal streaking. The patient had an adequate vascular supply with easily palpable pedal pulses and a capillary refill time that was within normal limits. The patient’s white blood cell count was 8.7 at admission.
An initial X-ray showed no visible signs of osteomyelitis or a foreign body. The MRI showed increased marrow edema of the fibular sesamoid consistent with osteomyelitis with no foreign bodies or abscesses present.
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.
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.
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.
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.