Updated: 6/7/2021

Foot Puncture Wounds

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  • Summary
    • Foot Puncture Wounds are common work place injuries which are at high risk for soft tissue infection and development of osteomyelitis.
    • Diagnosis is clinical with inspection of the plantar foot for the puncture site as well as surrounding erythema and drainage. MRI studies are indicated when there is concern for osteomyelitis. 
    • Treatment can be observation with antibiotics or surgical debridement depending on chronicity of wound, patient comorbidities and presence of soft tissue infection or osteomyelitis. 
  • Epidemiology
    • Incidence
      • common injury in certain work-places (i.e. construction sites)
        • approximately 10% develop infection
        • approximately 1-2% develop osteomyelitis
  • Etiology
    • Pathophysiology
      • mechanism of injury
        • usually stepping on a nail or stick through a sock/sole of foot
      • microbiology
        • most common cause of soft tissue infection is Staph aureus
        • most common cause of osteomyelitis is pseudomonas
  • Presentation
    • Presentation
      • often present weeks to a month after initial injury
      • limp
    • Physical exam
      • swollen and tender foot
      • obvious wound, with or without tract
      • well-demarcated erythema
      • may present with lymphadenopathy
  • Imaging
    • Radiographs
      • required views
        • ap and lateral
      • findings
        • normal early
        • bone destruction seen later
        • exclude presence of foreign body
    • MRI
      • indications
        • obtain prior to operative irrigation and debridement
        • used to rule out osteomyelitis
          • may occur in 1-2%
  • Treatment
    • Nonoperative
      • tetanus booster, prophylactic antibiotics (controversial)
        • indications
          • recent (within hours) puncture wound with no evidence of infection
          • if open wound, bedside irrigation and debridement
          • no standard prophylactic abx for acute (within hours) injury, but should cover for Pseudomonas
    • Operative
      • surgical debridement
        • indications
          • late/delayed presentation with deep infection with/without osteomyelitis
          • foreign body removal
          • no improvement with PO antibiotics
        • technique
          • tract and soft tissue debridement
          • deep culture
          • bony curretage (if osteo)
          • packing with wick to allow for healing by secondary intention
        • postoperative
          • follow with IV antibiotics (coverage for pseudomonas)
          • convert to PO antibiotics once clinical picture improves
          • antibiotic choice
            • preferred antibiotics
              • ciprofloxacin or levofloxacin (except in children)
              • alternative antibiotics: ceftazidime or cefepime
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(OBQ13.273) A 37-year-old healthy construction worker presents 1 week after stepping on a nail at work. He reports continued pain, fever, and drainage, and his clinical photo is shown in Figure A. Treatment with 7-days of amoxicillin - clavulanic acid did not improve his symptoms. Which additional antibiotic are you most likely to prescribe?

QID: 4908
FIGURES:
1

Doubling the dose of Amoxicillin

5%

(174/3429)

2

Trimethoprim and sulfamethoxazole

15%

(524/3429)

3

Ciprofloxacin

68%

(2341/3429)

4

Rifampin

4%

(126/3429)

5

Vancomycin

7%

(247/3429)

L 3 B

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