Management of Plantar Puncture Wounds
Hazel Guinto-Ocampo
Introduction
The feet are the most common site for puncture wounds (1). The vast majority of plantar puncture wounds are caused by nails and generally occur during the summer (2,3). These injuries are common among children and account for 0.8% of emergency department (ED) visits (2). With the exception of hand puncture wounds, plantar puncture wounds have a higher complication rate than puncture wounds elsewhere in the body (1). These complications include soft-tissue infections, mostly caused by Staphylococcus and Streptococcus species, and osteomyelitis, of which 90% are caused by Pseudomonas species (2,4,5,6,7,8,9,10,11,12,13,14,15,16,17). The development of infectious complications has been associated with retained foreign bodies (4,18). Puncture wounds through sneakers have been implicated in pseudomonal infections (13,19).
When evaluating plantar puncture wounds, the following information should be obtained and documented: history of immunocompromise; tetanus immunization status; size, nature, and condition of the object that caused the puncture; potential for contamination or presence of a foreign body; prehospital care; site of injury; footwear and clothing penetrated; and elapsed time since the injury.
Coring or enlargement of the puncture site may be beneficial in contaminated wounds or those with a possible foreign body by allowing improved visualization, irrigation, and drainage. Physicians or other health care providers in the office or ED setting can easily perform this procedure.
Anatomy and Physiology
The foot can be divided into three zones (20) (Fig. 110.1). Because of the close proximity of the tarsal bones to the skin surface and the greater force exerted on this weight-bearing area, puncture wounds in Zone 1 penetrate deeper and have the highest risk of infectious complications (21,22), followed by Zone 2 and, lastly, Zone 3. Complications include cellulitis, soft-tissue abscess, foreign body granuloma, pyarthrosis, and osteomyelitis. Infections occurring in the first few days following the puncture are most commonly due to Staphylococcus aureus or group A streptococci (5). Pyarthrosis and osteomyelitis secondary to puncture wounds are overwhelmingly due to Pseudomonas aeruginosa (9,10,11,12,13,14,15,16,17,18,19). The incidence of infections is reportedly as high as 15% (2), with the incidence of osteomyelitis estimated to be 0.4% to 0.6% (23). It should be noted that such estimates are likely high, as a large percentage of patients do not seek medical attention for superficial puncture wounds (24). Patients presenting late (7 days or more) are at increased risk for infectious complications (2). In addition, children appear to be at greatest risk for permanent sequelae as a result of these infections (3). Most puncture wounds are considered to be tetanus prone and thus require tetanus prophylaxis (see Table 107.2).
Indications
The management of plantar puncture wounds is controversial (1,23,25). Exploration of plantar puncture wounds for foreign bodies is technically difficult. Plantar skin is thick, relatively rigid, and sensitive. Because of the narrowness of puncture wounds, they are difficult to effectively irrigate, and locating foreign bodies that penetrate the plantar fascia is almost impossible (1). Management strategies include expectant therapy, surface cleansing without exploration (26), simple probing and grasping, trimming jagged epidermal skin edges (27), and wound exploration through coring or
enlargement of the puncture wound by removal of a block of tissue (11,28,29). The percentage of foreign bodies that are discovered and successfully removed and the percentage of infections averted following wound exploration are unknown. High-pressure wound irrigation, deep probing, and extensive tissue débridement have not been shown to improve outcome (2,23,28,30). The potential for delayed wound healing and the discomfort associated with wound exploration and débridement must be weighed against the benefit of preventing infectious complications.
enlargement of the puncture wound by removal of a block of tissue (11,28,29). The percentage of foreign bodies that are discovered and successfully removed and the percentage of infections averted following wound exploration are unknown. High-pressure wound irrigation, deep probing, and extensive tissue débridement have not been shown to improve outcome (2,23,28,30). The potential for delayed wound healing and the discomfort associated with wound exploration and débridement must be weighed against the benefit of preventing infectious complications.