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Overview of puncture wounds

INTRODUCTION

Puncture wounds, particularly to the plantar surface of the foot, are common and occur in all age groups. For example, over 7 percent of patients with lower extremity trauma who presented to an emergency department in one survey had plantar puncture wounds [1]. Patients seek medical attention for these wounds for a variety of reasons including:

  • Questions about the need for tetanus immunization
  • Pain relief
  • Treatment of established infection involving soft tissues or musculoskeletal structures

The clinical aspects and treatment approach to puncture wounds are reviewed here. Puncture wounds that occur in specialized settings such as water exposure are discussed separately. (See "Soft tissue infections following water exposure".)

EPIDEMIOLOGY

Puncture wounds can occur in a broad array of circumstances. The majority of plantar puncture wounds are due to nails; less commonly, glass, wood, or other metal objects besides nails are the source of the puncture. In one series of children, these wounds occurred more often in the months of May through October [2]. Superficial wounds generally heal without complications, but deeper penetration from the puncture is a risk factor for more serious infection. Puncture wounds of the metatarsal-phalangeal joints or surrounding tissue often penetrate deeper because this is a weight-bearing area [3].

Serial analysis of a patient population over a seven-year period has identified risk factors for infection [4-6]. The risk of infection was increased in patients who had either puncture wounds to the forefoot or wore shoes at the time of injury. A case control study evaluated 146 patients hospitalized with puncture wounds, 77 of whom had diabetes mellitus, some with neuropathy [5]. The diabetic patients presented to clinicians later following puncture injury than patients without diabetes (8.7 versus 5.3 days) and more often developed osteomyelitis (35 versus 13 percent). They were also five times as likely to require multiple operations and 46 times as likely to have a lower extremity amputation [6].

            

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Literature review current through: Jul 2014. | This topic last updated: Jun 19, 2013.
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References
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  1. Reinherz RP, Hong DT, Tisa LM, et al. Management of puncture wounds in the foot. J Foot Surg 1985; 24:288.
  2. Fitzgerald RH Jr, Cowan JD. Puncture wounds of the foot. Orthop Clin North Am 1975; 6:965.
  3. Chisholm CD, Schlesser JF. Plantar puncture wounds: controversies and treatment recommendations. Ann Emerg Med 1989; 18:1352.
  4. Lavery LA, Harkless LB, Ashry HR, Felder-Johnson K. Infected puncture wounds in adults with diabetes: risk factors for osteomyelitis. J Foot Ankle Surg 1994; 33:561.
  5. Lavery LA, Walker SC, Harkless LB, Felder-Johnson K. Infected puncture wounds in diabetic and nondiabetic adults. Diabetes Care 1995; 18:1588.
  6. Armstrong DG, Lavery LA, Quebedeaux TL, Walker SC. Surgical morbidity and the risk of amputation due to infected puncture wounds in diabetic versus nondiabetic adults. South Med J 1997; 90:384.
  7. Koh TH, Sng LH, Yuen SM, et al. Streptococcal cellulitis following preparation of fresh raw seafood. Zoonoses Public Health 2009; 56:206.
  8. 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.
  9. Lammers RL, Magill T. Detection and management of foreign bodies in soft tissue. Emerg Med Clin North Am 1992; 10:767.
  10. Chudnofsky CR, Sebastian S. Special wounds. Nail bed, plantar puncture, and cartilage. Emerg Med Clin North Am 1992; 10:801.
  11. Raz R, Miron D. Oral ciprofloxacin for treatment of infection following nail puncture wounds of the foot. Clin Infect Dis 1995; 21:194.
  12. Jacobs RF, McCarthy RE, Elser JM. Pseudomonas osteochondritis complicating puncture wounds of the foot in children: a 10-year evaluation. J Infect Dis 1989; 160:657.