Puncture Wounds

Foot Puncture

Foot Puncture

Recently, my father who is a diabetic, was working outside when he stepped on a nail. Normally, I wouldn’t mind when some random medical history of his gets to me second hand, but for a podiatrist, I would’ve hoped he would have contacted me immediately. Then, he proceeded to tell me what he did about his puncture wound. I suppose he already knew what to do because his son is a podiatrist.

You’re not the only one
Of all of the trauma to the lower extremity that is seen in the emergency department, about 7.5% are puncture wounds.1 Obviously, it is much more common in the warmer months, with more outdoor activities to enjoy and many enjoying the warmer weather without shoes. May through October are the more prevalent times for puncture wounds, with July having the most.

Nails are the most common culprit, but anything that is sharp, can puncture the foot: metal, tree branches, glass, wire, a plastic spike, a rock, sewing needles, wood (toothpicks), fish spines, steak bones, coral, and graphite, to name a few.(1)

Why go to the doctor?
If the skin is pierced, bleeding occurs, the object is dirty, or rusty, if the object penetrated deep or if there is visible tissue damage that requires more than a bandaid, you should be seen by a doctor within 24 hours. If all or part of the offending object is stuck in the foot, visible or not, you should go to the urgent care or Emergency department. Studies show that the quicker a patient has their wound taken care of, the less likely it is to cause an infection.

Do I need antibiotics?
Really, if you consider the amount of bacteria EVERYWHERE, on EVERY surface, you may realize that you may need antibiotics to help your body prevent a bigger problem. The recommendation is to give antibiotics “prophylactically,” or in a preventative measure. Similarly, antibiotics are given prophylactically in the operating room prior to surgery, and that is a clean/sterile environment. If your wound is red, warm/hot, and swollen, you need antibiotics as those are the cardinal signs of infection.

Foot Puncture X-Ray

Foot Puncture X-Ray

Should I soak my foot?
A common treatment in the past, soaking the foot has not shown to be beneficial after a puncture wound. In fact, it can lead to more complications. The answer here is a clear: No!

Tetanus prophylaxis
If the wound is greater than 6 hours old, larger than 1cm in depth, has signs of infection, damaged tissue, contaminants, the wound is more likely to develop an infection due to tetanus. Rusty, dirty nails are the main culprits. If you haven’t received the series of tetanus shots within 10 years, you need to get a tetanus shot. A booster is required if the above conditions are met and it has been a year since your last tetanus shot, or within 5 years if the wound isn’t tetanus prone.

Parting thoughts – What I would do
What is clear is that aggressive, early primary wound care has the greatest impact in preventing infection.1 Delay between the time of injury and the initiation of treatment is perhaps the most critical factor in determining whether or not an infection develops and the severity of complications following a puncture wound. Also, knowing that 3% of wounds retain some foreign body and that is usually instrumental in causing infection that would not respond to antibiotic therapy.1 I would first make a call to your podiatrist. You may be able to by-pass the emergency room and get in to see the specialist that day. Otherwise, seek medical attention and prevent greater problems.

References and Images:
1. McGlamry’s Comprehensive Textbook of Foot and Ankle Surgery, 4th Ed. 2013.Chapter 84
2. Rusty Nail in a wood Plank. background-pictures.picphotos.net
3. Screwdriver stuck in the foot. www.giantbomb.com

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