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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.

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Pathophysiology

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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

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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.

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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

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Table Graphic Jump Location
Table 50-1 Risk Factors for Puncture Wound Complications 
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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.

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Clinical Features

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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 ...

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