Updated: 2/24/2020

Foot Puncture Wounds

Topic

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Questions

9 9

Evidence

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Introduction
Epidemiology common injury in certain work-places (i.e. construction sites) approximately 10% develop infection approximately 1-2% develop osteomyelitis 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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Questions (9)

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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? Tested Concept

QID: 4908

FIGURES:

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Doubling the dose of Amoxicillin

(174/3202)

Trimethoprim and sulfamethoxazole

15%

(493/3202)

Ciprofloxacin

68%

(2187/3202)