Updated: 4/5/2019

Foot Puncture Wounds

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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 (7)
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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? Review Topic

QID: 4908
FIGURES:
1

Doubling the dose of Amoxicillin

6%

(174/2738)

2

Trimethoprim and sulfamethoxazole

16%

(427/2738)

3

Ciprofloxacin

67%

(1830/2738)

4

Rifampin

4%

(112/2738)

5

Vancomycin

7%

(181/2738)

ML 3

Select Answer to see Preferred Response

PREFERRED RESPONSE 3
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