Puncture wounds of the foot
Objectives- Describe the natural history of an untreated puncture wound of the foot the 1) penetrates only soft tissue, and 2) penetrates the metatarsal head
- Describe the incidence of cellulitis and osteomyelitis after initially treated puncture wounds of the foot
- Discuss the role of footwear in the genesis of Pseudomonas osteomyelitis of the foot secondary to a puncture wound
- Describe a treatment plan for 1) initial management of a puncture wound of the foot, and 2) delayed presentation of a clinically inflamed great toe following a puncture wound
Discussion points
- What is optimum initial management for an innocent appearing puncture wound? For an obviously dirty wound?
- What is the risk of osteomyelitis if the patient sustaining a puncture wound is barefoot?
- What is the data base for current recommendations for antibiotic management of osteomyelitis secondary to puncture wounds?
- What is the effect of delayed diagnosis on prognosis?
- Are laboratory studies valuable in the assessment of osteomyelitis following puncture wound?
Discussion
Since the 1960's, a number of reports of puncture wound of the foot have clearly established the pathogenesis and management of this entity. 98% of puncture wounds result from stepping on a nail. Cellulits subsequently develops in 8-15%, osteomyelitis in 0.6-1.8%. The prevalence of Pseudomonas as the offending organism appears to be a result of its presence in the sole of tennis shoes; although it has also been found in work boots, any warm moist environment can foster its presence. There are no fixed protocols for the initial management a puncture wound; debridement and irrigation with a 19G needle have been recommended. Especially dirty wounds do warrant initial debridement. Soft tissue infections are generally secondary to staph aureus, and bone or cartilage are secondary to pseudomonas, so no antibiotics are indicated at the time of injury. Laboratory values are normal and are not helpful. Typically, the patient will re-appear at 2-3 days or later if cellulitis or osteomyelitis has occurred. Wound exploration is indicated and if bone or joint infection has occurred, one of the newer beta-lactam antibiotics are usually administered, ceftazidime is presently favored. The duration of therapy necessary has not been established; it is interesting to note that one of the first patients reported with this problem, by Johanson, was treated only with surgical debridement. A 5 to 7 day course of antibiotics is probably sufficient if adequate debridement has been performed. Prognosis seems directly related to delay in diagnosis after injury. Green and Bruno reported minimal complications with early treatment. If there was a 10 to 14 day delay, there was sometimes residual deformity. A week delay essentially assured residual deformity.
References
- Fisher MC, Goldsmith kJF, Gilligan PH. Sneakers as a source of pseudomonas aeruginosa in children with osteomyelitis following puncture wounds. J Pediatr 1985; 106: 607-09.
- Green NE, Bruno j. Pseudomonas infection of the foot after puncture wounds. South Med J 1980; 73( 146-49).
- Jacobs RF, McCarthy RE, Elser JM. Pseudomonas osteochondritis complication puncture wounds of the foot in children. A 10 year evaluation. J Infect Dis 1989; 160: 657-61.
- Jarvis JG, Skipper J. Psedomonas osteochondritis complicating puncture wounds in children. J Pediatr Orthop 1994; 14: 755-9.
- Johanson PH. Pseudomonas infections of the foot following puncture wounds. JAMA 1968; 204: 170-72.
- Laughlin TJ, Armstrong DG, Caporusso J, Lavery LA. Soft tissue and bone infections from puncture wounds in children. Western Journal of Medicine 1997; 166( 2): 126-8.
- Niall DM, Murphy PG, Fogarty EE, Dowling FE, Moore DP. Puncture wound related pseudomonas infections of the foot in children. Irish Journal of Medical Science 1997; 166( 2): 98-101.
- Verdile VP, Freed H, Gerard J. Puncture wounds to the foot. J Emerg Med 1989; 7: 193-99.
May 16-19, 2012 in Denver, CO
