Puncture wounds are defined as wounds whose depth exceeds the
diameter of the visible surface injury. They most commonly involve
the plantar surface of the foot.1 The relatively
innocuous-appearing skin wound belies the potential for infection
and injury to underlying structures. Puncture wounds caused by high-pressure
injection equipment, animal bites, and those involving exposure
to body fluids each have the potential for unique complications
that affect ED evaluation and management.
In puncture wounds, shear forces between the penetrating object
and tissue result in tissue disruption, producing hemorrhage and
devitalization of skin and underlying tissues. Inoculation of organisms
from the object (with or without leaving behind a subdermal foreign
body) or from the skin surface into the deeper tissues is followed
by relatively rapid closure of the small skin wound, creating an
environment favorable for the development of infection as evidenced
by the reported infection rate from plantar puncture wounds of approximately
6% to 11%.2,3
Most soft tissue infections from puncture wounds are caused by
gram-positive organisms. Staphylococcus aureus predominates,
followed by other staphylococcal and streptococcal species.2,4–7 Puncture
wounds over joints can penetrate the joint capsule and produce septic
arthritis, whereas penetration of cartilage, periosteum, and bone
can lead to osteomyelitis. Pseudomonas aeruginosa is
the most frequent pathogen isolated from plantar puncture wound–related
osteomyelitis, particularly when the injury occurs through the rubber
sole of an athletic shoe.6–8 The bacterial
source appears to be the foam lining of athletic shoes, as Pseudomonas has
been cultured from this location.
Difficulty in visualizing and accessing the entire extent of
injury with puncture wounds contributes to the higher risk for infection
when compared to traumatic lacerations. Other host and wound factors
associated with delayed healing and/or infection apply
to puncture wounds as well (Table 50-1).9
Table 50-1 Risk Factors for Puncture Wound Complications
| Save Table
Table 50-1 Risk Factors for Puncture Wound Complications
|Immunocompromised (diabetes, acquired immunodeficiency
syndrome, steroids, chemotherapy)|
|Peripheral vascular disease|
|Contaminated with soil or debris|
|Containing foreign body|
|Occurring through a shoe and/or sock|
|Occurring >6 h before evaluation|
|Deeper penetration (jumping, falling, running)|
Most literature related to plantar puncture wounds identifies
forefoot injuries as inherently higher-risk. Theoretically, because
most of the body weight is transmitted to the metatarsal heads during
walking, a puncture in this area might penetrate deeply. Published
case series of patients hospitalized with infected plantar puncture
wounds both supports6,10 and refutes7 this
theory. Therefore, the assertion that forefoot injuries have a higher
infection rate remains in dispute.
Important historical features related to puncture wounds include
the time of injury as well as circumstances leading up to the injury.
A report of high-pressure injection or of falling or jumping onto
an object suggests deeper penetration with potential for greater
injury. The footwear (for plantar injuries) or clothing through
which the object passed will help assess the potential for foreign
body and infection. The patient’s estimate of depth as
well as foreign body sensation should be sought. The patient should
be asked about postinjury care rendered before presentation. The
medical history should inquire about host factors predisposing to
Characteristics of the penetrating object are important in predicting
risk of a retained foreign body and postinjury infection. Some materials,
such as wood, glass, or plastic, are prone to break or splinter,
leaving retained fragments in the wound. Thin objects, such as needles
or pins, can break off cleanly beneath the skin surface, leaving
a fragment behind.
Physical examination of puncture wounds should assess wound characteristics
as well as function of underlying structures. The size and location
of the wound should be determined as well as the condition of surrounding
skin and presence of foreign matter or devitalized tissue. Puncture
wounds should be inspected for their proximity to underlying structures.
Distal function of tendons and nerves and integrity of distal perfusion
should be assessed, especially with puncture wounds of the hand.
Patients with puncture wounds may not present until infection has developed,
suggested by progressive pain that developed a few days after the
event, swelling, erythema, warmth, fluctuance, drainage, or pain
with motion of tendons or joints.
Because the entire depth of a puncture wound cannot be reliably
explored, assessment for the presence of a foreign body is problematic.
Patient perception of a foreign body is modestly useful in predicting
the presence of one.11,12 The practice of probing
of the wound with a blunt instrument to assess depth and the presence
of a foreign body is of unproven utility.
Plain-film radiographs utilizing soft tissue visualization techniques
are indicated in all infected puncture wounds, in wounds caused
by materials prone to fragment, and whenever the patient reports
a foreign body sensation (see Chapter 49, Soft Tissue Foreign Bodies). Plain radiographs will detect >90% of
radiopaque foreign bodies >1.0 mm in diameter (Figure 50-1). Most organic substances, such as wood, thorns, and other
plant matter, have radiodensities close to that of soft tissue and cannot
reliably be detected in puncture wounds with plain radiographs.
Puncture wound to heel. A. Physician enlarged
the wound in an unsuccessful attempt to locate and remove foreign
body. B. Radiograph showing retained foreign body.
Ultrasonography can identify soft tissue foreign bodies, but
the ability to detect small objects that might have been introduced
through a puncture wound is limited. CT can accurately detect radiolucent
foreign bodies and is the imaging modality to use when a retained
foreign body is ...