Puncture Wounds of the Foot

By admin Last updated Feb 25, 2024

Ovid: 5-Minute Orthopaedic Consult

Editors: Frassica, Frank J.; Sponseller, Paul D.; Wilckens, John H.

Title: 5-Minute Orthopaedic Consult, 2nd Edition

> Table of Contents > Puncture Wounds of the Foot

Puncture Wounds of the Foot

Gregory Gebauer MD, MS

Basics

Description

Puncture injuries of the foot typically occur on the plantar surface of the forefoot or heel.
The injuring object usually is a nail,
needle, or pin, but it can be anything that punctures the soft tissue,
including thorns, glass, and splinters.
Classification:
- Early presentation: Day of injury
- Late presentation: At least 3–5 days after puncture, when deep infection develops

General Prevention

Avoid going barefoot outdoors or in areas with debris such as wood fragments or nails.

Epidemiology

Anecdotally, this injury is more common in children.
Males are affected more often than females.

Incidence

Puncture wounds of the foot constitute 0.5–1% of all emergency room visits by children (1).
Only 0.6% of children with puncture wounds develop deep infection (1).

Risk Factors

Walking barefoot
Construction work

Etiology

The penetrating object carries with it organisms from the soil, the skin, or a sock or shoe sole, if these are worn.
- Pseudomonas and other atypical infections are common.
Many times, the flora is polymicrobial.
Usually, the site developing infection is a synovial-lined space such as a tendon sheath, joint, plantar bursa, or bone.

Diagnosis

Signs and Symptoms

Acute phase:
- Pain
- Swelling
- Bleeding
Late presentation:
- Redness
- Tenderness
- Cellulitis
- Fluctuance or drainage (purulent or serous)
- Patient may limp, refuse to bear weight, or walk on the heel to avoid pressure on the forefoot.

History

Timing of injury
Location of injury, degree of environmental contamination
Absence or presence of shoe wear at time of puncture wound

Physical Exam

Early presentation:
- Inspect to assess the depth, severity, and contamination of the soft tissue.
- Palpate the area to determine if any evidence of a retained foreign body is present.
- Evaluate for joint involvement by proximity of the puncture wound and examination of joint ROM.
- Examine shoe wear for evidence of penetration.
Late presentation:
- Evaluate for local and systemic evidence of infection.
  - Erythema
  - Swelling
  - Cellulitis
  - Fluctuance
  - Enlargement of lymph nodes (popliteal, inguinal)
- Check for pain with ROM of the adjacent joints.
  - MTP joint
  - IP joint
  - Midfoot joint
- Circumferential or dorsal swelling likely indicates a deep infection.

Tests

Late presentation:
- Area of infection (joint, bursa or tendon
  sheath) may be aspirated to obtain Gram stain and culture to identify
  an organism, which may guide treatment.

Lab

Early presentation: Usually not needed
Late presentation (infection suspected): The following can be helpful, although not specific.
- White blood cell count with differential
- ESR
- C-reactive protein

Imaging

Plain radiography:
- To rule out associated fracture, bony involvement, or retained foreign body
- In late presentations, also may evaluate for osteomyelitis or gas in tissue
MRI:
- May be reserved for difficult cases with deep involvement
- Can identify abscess, osteomyelitis, and in some cases, retained foreign body
Ultrasound:
- Can diagnose abscess
- Can identify foreign body retained in foot
Nuclear medicine imaging:
- Alternative to MRI
- May help differentiate local inflammation from osteomyelitis

Diagnostic Procedures/Surgery

Local wound exploration should be performed to determine the extent of the wound and assess for any contamination.

Differential Diagnosis

Osteomyelitis
Septic arthritis
Tenosynovitis
Septic bursitis of the foot
Cellulitis

P.349

Treatment

General Measures

Acute presentation:
- Local irrigation and débridement are indicated.
- Debate arises whether prophylactic antibiotics are necessary for patients with acute puncture.
- Tetanus prophylaxis booster should be given.
- Instruct the patient to return if signs of deep infection develop.
Late presentation:
- Deep infections require surgical irrigation and débridement, and tissue cultures should be obtained.
- Soft-tissue infections are often Gram-positive Staphylococcus or Streptococcus, but Pseudomonas is not uncommon.
- If the patient presents with cellulitis,
  aspiration should be attempted, and the patient should be treated
  empirically with oral or intravenous therapy for 24 hours with clinical
  evaluation.
  - If the condition improves, the patient should complete a 5-day course of oral antibiotics.
  - If the condition does not improve, or if Pseudomonas is recovered from the aspirate, surgical drainage is preferred.
- Areas of fluctuance should be incised and drained.
- For patients with a small, localized abscess that has been drained adequately with no other evidence of infection:
  - Broad-spectrum oral antibiotic coverage
    probably is adequate initially, but it should be changed to a
    culture-specific treatment as soon as possible.
  - Weightbearing activity may be resumed as tenderness resolves.

Medication

Acute puncture:
- Antibiotic treatment remains controversial: It may not be indicated, but a short course may be prudent.
Late presentation:
- After aspiration, administer antibiotics that are effective against Gram-positive organisms.
- Add an antibiotic effective against Pseudomonas if this organism is recovered from cultures or if symptoms do not resolve.

Surgery

If needed, the site of infection should be localized by physical examination or plain radiography.
- Occasionally, MRI is needed.
The approach should be the most direct to
the pathologic features and should follow the tract of the puncture
wound, if possible.
Plantar incisions are acceptable,
although they should be positioned to avoid pressure points such as the
heel or ball of the foot.
Thorough débridement should be performed.
Cultures should be sent for identification, including Mycobacterium, if clinically indicated.

Follow-up

Prognosis

Generally good
Complications include cellulitis, abscess, osteomyelitis, and septic arthritis.
The rate of subsequent osteomyelitis is ~0.6–1.8% (1).

Complications

Rate of complications in 1 study was 3.2% (1).
Osteomyelitis (rare)
Septic arthritis (rare)

Patient Monitoring

Follow-up examination is performed by a primary care physician or a specialist if symptoms persist.

References

1. Fitzgerald RH, Jr, Cowan JD. Puncture wounds of the foot. Orthop Clin North Am 1975;6:965–972.

Additional Reading

Fisher MC, Goldsmith JF, Gilligan PH. Sneakers AS a source of Pseudomonas aeruginosa in children with osteomyelitis following puncture wounds. J Pediatr 1985;106:607–609.

Green NE. Musculoskeletal infections in children. Part IV. Pseudomonas infections of the foot following puncture wounds. Instr Course Lect 1983;32:43–46.

Reichl M. Septic arthritis following puncture wound of the foot. Arch Emerg Med 1989;6:277–279.

Miscellaneous

Codes

ICD9-CM

682.7 Cellulitis/abscess foot
711.07 Pyogenic arthritis ankle and foot
730.07 Acute osteomyelitis ankle and foot

Patient Teaching

After an acute puncture wound, patients should be
instructed about the signs and symptoms of infection and told to return
if these occur.

FAQ

Q: How should an acute puncture wound be treated?

A:
Puncture wounds that present early should be thoroughly cleaned and
irrigated. Foreign bodies should be removed. Antibiotics are not
necessarily required. Wounds that present late with signs of infection
require aggressive irrigation and débridement and antibiotic therapy.

Q: What are the most common pathogens?

A: The most common organisms in infected puncture wounds are skin flora, commonly Gram-positive cocci.
Pseudomonas
is not an uncommon pathogen and should be suspected in wounds that fail
to respond to initial treatment or that show signs typical of this
organism (blue-green tinted, foul-smelling, or musty discharge).