Puncture Wound

Aka: Puncture Wound, Plantar Puncture Wound, Puncture Wound of Sole of Foot, Foot Puncture Wound

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II. Pathophysiology

  1. See Sweaty Tennis Shoe Syndrome
  2. Foreign body Puncture Wound
    1. Bottom of foot (plantar) affected in 50% of cases
      1. See Sweaty Tennis Shoe Syndrome (infection with Pseudomonas aeruginosa)
    2. Other common sites: Knees, Arms and hands
  3. Puncture causes
    1. Nails (account for 90% of cases)
    2. Other common causes: wood, metal, plastic and glass

III. Causes of Infection

  1. Soft tissue infections
    1. Staphylococcus
    2. Streptococcus
    3. Pseudomonas aeruginosa (Sweaty Tennis Shoe Syndrome)
    4. Mixed flora (toothpick Puncture Wound)
  2. Osteomyelitis (or Osteochondritis)
    1. Pseudomonas Osteochondritis (90% of cases)

IV. Risk factors for complication (especially infection)

  1. Depth of wound (most important factor)
  2. Retained Foreign Body
  3. Presentation beyond 24 hours

V. Complications

  1. Osteomyelitis (1-2% of Plantar Puncture Wounds in children)
  2. Severe soft tissue infection (6-10% of punctures)
  3. Tattoing of skin by debris (dirt, lead, ink)
  4. Neurovascular compromise (rare)

VI. Radiology

  1. Foot xray
    1. Consider to identify Retained Foreign Body
    2. Glass and metal are radio-opaque
  2. Ultrasound or Computed Tomography
    1. Indicated for Radiolucent Foreign Body (e.g. wood)

VII. Management: General

  1. Administer Tetanus Prophylaxis (Tetanus Vaccine)
  2. Clean wound
    1. Clean external wound edges
    2. Irrigate, debride and explore larger wound sites
      1. Under Local Anesthesia or regional Nerve Block
      2. Clean jagged wound edges
  3. Remove introduced foreign bodies if possible
    1. Consider soft tissue Ultrasound for foreign body localization
    2. Consider orthopedic removal under fluoroscopy
    3. Important foot structures threatened
    4. Foreign body causes pain
    5. Potential for allergic response
  4. Avoid harmful procedures or that do not improve outcome
    1. Avoid high pressure irrigation
    2. Avoid deep probing
    3. Avoid extensive Debridement or coring

VIII. Management: Antibiotics

  1. Indications
    1. Infected wound entry site
    2. Presentation more than 24 hours after puncture
  2. Cases in which Antibiotics are not usually indicated
    1. Presentation within 24 hours of Puncture Wound
    2. Prophylaxis of Pseudomonas infection is not indicated
  3. Staphylococcus or Streptococcus Coverage
    1. Oral Antibiotic for Localized Cellulitis
      1. Cephalexin (Keflex)
      2. Amoxicillin-Clavulanic acid (Augmentin)
      3. Dicloxacillin
      4. Erythromycin
    2. ParenteralAntibiotics for severe infection
      1. Cefazolin (Ancef)
      2. Ampicillin-Sulbactam (Unasyn)
      3. Timentin
      4. Piperacillin
  4. Pseudomonas aeruginosa coverage
    1. Local infection: Sweaty Tennis Shoe Syndrome
    2. Osteomyelitis: Pseudomonas Osteochonditis

IX. Follow-up

  1. Consider re-examination in 48 hours

X. References

  1. (2019) Sanford Guide, accessed on IOS 2/17/2020
  2. Baldwin (1999) Pediatr Rev 20(1):21-3 [PubMed]
  3. Rubin (2010) J Foot Ankle Surg 49(5):421-5 [PubMed]
  4. Wedmore (2000) Emerg Med Clin North Am 18(1):85-113 [PubMed]

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