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Puncture wounds can be challenging to manage due to difficulty visualizing and cleaning the full depth of an injury. These injuries commonly occur to the extremities, such as on the plantar surface of the foot. Puncture wounds also include injuries caused by high-pressure injection equipment, health care associated needle-stick injuries, and some bite wounds from animals. Infections are reported in 6% to 11% of puncture wounds, with Staphylococcus aureus predominating (including methicillin-resistant S. aureus—MRSA). Pseudomonas aeruginosa is the most common pathogen in post-puncture wound osteomyelitis, particularly when penetration occurs through the sole of an athletic shoe. Post-puncture wound infections despite treatment with antibiotics suggest the possibility of a retained foreign body.

Clinical Features

Puncture wounds treated more than 6 hours after they occur have a greater risk of infection. Wood, glass, or plastic materials may break or splinter when an injury occurs, increasing the chance for retained fragments within the puncture track. Patient perception of a foreign body may be useful for predicting the presence of such a contaminant or fragment.

On physical examination, assess the wound and the likelihood of injury to structures beneath the skin by evaluating distal function of tendons, nerves, and blood vessels. Inspect the wound location, condition of surrounding skin, and the potential presence of foreign matter, debris, or devitalized tissue. Signs of infection include significant pain, swelling, erythema, warmth, fluctuance, decreased range of motion, or drainage from the site.

Diagnosis and Differential

Plain film radiographs should be obtained for any wound suspected of having a potential radiopaque retained foreign body (Table 15-1).

Table 15-1

Risk Factors for Puncture Wound Complications

Organic substances, such as wood or plant matter, are not reliably detected by plan radiographs, but >90% of radiopaque foreign bodies that are >1 mm in diameter can be found this way. CT scan is the imaging modality to use when a retained foreign body continues to be suspected after negative plain film radiography.

Emergency Department Care and Disposition

Treatment recommendations for puncture wounds are based almost entirely on anecdotal evidence and uncontrolled case series.

  1. Uncomplicated, clean puncture wounds less than 6 hours after injury and without foreign body should have superficial wound cleansing and tetanus prophylaxis as indicated. Soaking has no proven benefit. Debridement or coring of the wound tract does not reduce rates of infection. There is no proven benefit of prophylactic antibiotics for ...

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