Charles A. Eckerline, Jr Jim Blake Ronald F. Koury
Cli.n.ic.al , .Features Treatment Complications Needle;Stick..lniiuries High-Pressure:lnjection..lniuries HumanBites pathophysiology
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Puncture wounds are usually accidental and usually involve the hands and soles of the feet. 1 Sharp, elongated objects that pierce the skin may penetrate into the deeper tissues, injuring underlying structures, introducing foreign bodies, and planting the inoculum for infection. Organized evaluation and management is necessary to minimize complications.
The most common sequela of puncture wounds is infection, which, depending on the location and puncturing instrument, is reported to occur from 6 to 11 percent of the time.23 Infection is more common in puncture wounds than in open lacerations because of inoculation of organisms into the deep tissues, followed by skin closure. Most infections from puncture wounds are due to gram-positive organisms, with Staphylococcus aureus predominating, followed by other staphylococcal and streptococcal species. Many other microorganisms have also been isolated from puncture wound infections, including Aerobacter aerogenes and Mycobacterium fortuitum. Puncture wounds over joints can penetrate through the joint capsule, producing septic arthritis. Penetration to the relatively vascular cartilage, periosteum, and bone can lead to osteomyelitis. Pseudomonas aeruginosa is the most frequent pathogen isolated post-puncture wound osteomyelitis, particularly when foreign-body penetration occurs through the sole of an athletic shoe. 45 Because this organism is not detected in new shoes, it has been postulated that the foam rubber material becomes colonized in the warm, humid summer months. Post-puncture wound infections are accentuated by the presence of a foreign body, and failure of an infection to respond to antibiotics suggests the presence of a retained foreign body.
Puncture wounds that present soon after injury generally appear simple and innocuous. Appropriate history should be obtained and documented: (1) the time interval since the injury (discomfort at >6 h increases the probability of infection), (2) type and condition of the penetrating object, (3) complete or partial removal of the object, (4) residual foreign-body sensation in the wound, (5) whether footwear was worn (plantar punctures), (6) an estimation of the depth of penetration, (7) whether the injury occurred indoors or outdoors, and (8) potential contamination (rust, dirt, cloth contaminants). A retained foreign body is suggested if the patient reports either the sensation of a retained object or incomplete removal of the penetrating instrument. The incidence of post-puncture wound infection is increased if the patient has decreased resistance to infection from diabetes mellitus, peripheral vascular disease, or immunosuppression. 6 As in the case of any wound, tetanus immunization status should be determined and appropriate prophylaxis performed.
Puncture wounds associated with an increased incidence of infection are those involving (1) more than 6 h from injury to presentation, (2) larger lesions with deeper penetration, (3) obvious contamination with foreign matter and debris, (4) occurrence outdoors, (5) penetration through footwear, (6) puncture of the forefoot, and (7) patients with poor resistance to infection (Fig 43-1)7
FIG. 43-1. The bony and cartilaginous structures in the forefoot region of the sole of the foot are the most prone to development of osteomyelitis after plantar puncture wounds.
Physical examination of puncture wounds should evaluate and document the wounds as well as the function of underlying structures. In puncture wounds of the hand, distal function of tendons (flexor and extensor), nerves (motor and sensory), and vessels (perfusion) should be assessed. Puncture wounds should be carefully inspected for their location, the condition of the surrounding skin, and the presence of foreign matter, debris, or devitalized tissue. Wound infection is suggested by increased pain, swelling, erythema, warmth, fluctuance, decreased range of motion at joints, or drainage from a wound site.
Because puncture wounds are potentially deep and cannot be easily inspected to their depth, there remains the possibility of a foreign body. Some materials are prone to break, leaving retained fragments behind: these include wood, glass, and plastic and thin objects such as pins and needles. Probing of the wound with a sterile, thin, blunt instrument is common practice to determine the depth of the wound and the presence of foreign body. However, this practice has not been validated in prospective studies. Wound probing is usually harmless and generally useless.
Plain-film radiographs should be obtained in all infected puncture wounds and in any wound suspicious for a retained radiopaque (metal, gravel, and glass) foreign body. Radiopaque foreign bodies greater than 0.5 to 1.0 mm in size will be identifiable in 80 to 90 percent of plain films. Radiographs should be obtained with multiple views and the "soft tissue" technique to maximize detection. Most organic substances—such as wood splinters, cactus spines, thorns, and vegetable matter—have radiodensities close to that of soft tissue and cannot be identified with plain-film radiographs. Ultrasound has been successfully used to identify substances invisible on plain films, although the reported sensitivity, specificity, and accuracy varies widely in experimental studies of this modality. Computed tomography (CT) is the
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