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10.15 Puncture wounds


Presentation

Most commonly, the patient will have stepped or jumped onto a nail. There may be pain and swelling but often the patient is only asking for a tetanus shot and can be found in the emergency department with his foot soaking in a basin of iodine solution. The wound entrance usually appears as a linear or stellate tear in the cornified epithelium on the plantar surface of the foot.

What to do:

What not to do:

Discussion:

Small, clean, superficial puncture wounds uniformly do well. The pathophysiology and management of a wound is dependent upon the the material that punctured the foot, the location, depth, time to presentation, footwear and underlying health status of the victim. Punctures in the metatarsal-phalangeal joint area may be of higher risk of bone and joint involvement. Children brought by a parent, adults with on-the-job injury and patients seeking tetanus shots tend to present earlier and thus have a lower incidence of infection. Patients who present after 24 hours may have an early subclinical infection. Unsuspected fragments of sock or rubber sole are a major source of potential infection.

When the foot is punctured, the cornified epithelium acts as a spatula, cleaning off any loose material from the penetrating object as it slides by. This debris often collects just beneath this cornified layer which then acts like a trap door holding it in. Left in place, this debris may lead to lymphangitis, cellulitis or abscess. Saucerization or excision of wound edges allows for the removal of debris and the unroofing of superficial small foreign bodies or abscesses found beneath the thickly cornified skin surfaces.

Osteomyelitis caused by Pseudomonas aeruginosa remains the most devastating sequela. The incidence of osteomyelitis is estimated to be between 0.4% and 0.6%. Nails through tennis shoes into the metatarsal heads are high risk injuries and should be referred for orthopedic follow up.

References:


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from Buttaravoli & Stair: COMMON SIMPLE EMERGENCIES
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