Foot Puncture Wounds - Foot & Ankle

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

Action	Numeric Key	Letter Key	Function Key
Show Bullets		S	Enter (frontside only)
20%	1	N
40%	2	H
60%	3	F	Enter (backside only)
80%	4	E
100%	5	M
Toss	0	T

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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:

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Doubling the dose of Amoxicillin

(174/3500)

Trimethoprim and sulfamethoxazole

15%

(535/3500)

Ciprofloxacin

68%

(2394/3500)