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Department of Pediatrics : Academic Divisions : Emergency Medicine : Resident Manual : Wound Care : Puncture Wounds

Most puncture wounds involve the plantar surface of the foot; therefore, that will be the focus of these guidelines. However, general guidelines apply to puncture wounds of other regions as well, except those involving the chest, abdomen, neck, and eye, which are beyond the scope of this manual. These guidelines are intended for uninfected wounds less than 24 hours old.

1. History:

  1. time of injury
  2. footwear, including socks (if foot injury)
  3. object causing puncture
  4. where injury occurred
  5. tetanus status
  6. suspicion of retained foreign body
  7. other medical problems (particularly immunosuppression)

2. Physical Examination:

  1. location of wound
  2. depth of wound
  3. tenderness to palpation or movement of toes
  4. neurovascular status
  5. any signs of infection

3. Administer tetanus prophylaxis, if indicated (see Red Book).

4. Obtain radiograph if retained foreign body is suspected but not visible on exam (most glass and metal objects will appear on a plain radiograph). Obtain xrays even if low suspicion for foreign body.

5. Use local anesthesia or a regional block if vigorous wound cleaning or debridement is indicated. Irrigate puncture site superficially with a syringe and splashguard or IV catheter, using copious amounts of sterile saline. The skin should be cleaned of foreign matter to avoid permanent tattooing. Avoid high-pressure deep wound irrigation, because it may damage tissue and push foreign bodies or bacteria deeper into the wound.

6. Aggressive surgical debridement, coring, and probing increase patient discomfort, and have not been proven beneficial. Loose skin or devitalized tissue should be trimmed to facilitate visualization of the wound tract.

7. Foreign bodies should be removed if they threaten vital structures, cause pain, contain substances that cause an allergic response, and are easily visible and readily accessible. The entrance wound can be enlarged with an adequate skin incision to allow exploration by spreading the soft tissue with a hemostat. If the foreign body is deep or in close proximity to a joint, tendon, vessel or nerve, surgical consultation should be obtained.

8. Consider orthopedic consultation for any patient with a deep puncture that may have entered bone or joint space, or in any patient with evidence on exam or radiograph of septic arthritis or osteomyelitis.

9. Dress the wound with bacitracin and sterile gauze.

10. Antibiotic therapy should be initiated for infected wounds. The most common type of infection in these patients is cellulitis, usually caused by staphylococci or streptococci. Most infections respond well to first-generation cephalosporins or Augmentin. There is insufficient evidence to recommend the use of prophylactic antimicrobials, and Pseudomonas osteomyelitis has occurred in patients on prophylactic therapy.

11. Prescribe rest, elevation, and intermittent warm water soaks. Patients and parents should be advised to return if signs and symptoms of wound infection occur. Patients with foreign bodies or infection on initial presentation should have follow up in 48 hours (by their physician or the ED).

References:

Baldwin G, Colbourne M. Puncture Wounds. Pediatr Rev 1999;20:21-23.

Fesmire FM, Dalsey WC, Howell JM et al. American College of Emergency Physicians: Clinical Policy for the Initial Approach to Patients Presenting with Penetrating Extremity Trauma. Ann Emerg Med 1999;33:612-636.

Wedmore IS. Emergency Department Evaluation and Treatment of Ankle and Foot Injuries. Emerg Med Clin North Am 2000;18(1):85-113.

Article reference:*

"Topical Anesthetics and Tissue Adhesives: A New Generation in Pediatric Wound Management"
By: Laura Sells, MD and Leslie Mihalov, MD
The Practical Journal of Pediatric Emergency Medicine - Emergency Medicine Report
September 1999

Emergency Medicine
Updates in Wound Management for the Pediatrician
By: Jane F. Knapp, MD
Pediatric Clinics of North America
Volume 46, Number 6, December 1999

*Refer to hard copy of manual

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