Plantar Puncture Wound

DIe Hard Glass in Feet

The best lesson learned from the first Die Hard movie = never take your shoes off and shoot out glass windows.

Ok, maybe I’m the only one who learned that lesson from the movie, but it is because I hate plantar puncture wounds!!  They are difficult to assess, can be deceptive, and prone to infection and complications: all things I also hate.

This is even accentuated in children.  Why? Because the common board exams instill a concern for Pseudomonas infections concurrent with this injury and this is not as easily managed in children.  We’ve been taught flouroquinolones shouldn’t be used in kids.  You wouldn’t want to have the kid’s joint to explode!! So what are you supposed to do?

Plantar Puncture Wounds

  • The Problem:

    • Plantar puncture wounds occur commonly. Especially during the summer months when people walk around barefoot.
    • The complex structure of the foot makes it an excellent environment for infection to hide and spread.
    • Puncture wounds, inherently, increase the risk of infection owing to the fact that the penetrating object (ex, nail, needle, etc) can implant foreign material deep into the foot’s architecture.
    • Puncture wounds that are more distal on the foot, which is where many occur, have a higher risk of infection.

 

  • The Concern:

    • Retained foreign bodies can be easily missed. The extent of the wound can be misleading.
    • While Staph and Strep are the most likely organisms to be responsible for a plantar infection, Pseudomonas is the one that we have all been taught to be fearful of and to tailor therapy to cover.
      • Pseudomonas loves rubber and plastic (not sure that that is actually true, as I have not interviewed the bug about its amorous relations, but nevertheless, it does seem to enjoy the company of rubber/plastic).
      • A penetrating injury that occurs through a shoe’s sole and foam inner lining can implant the pseudomonas from the shoe into the patient’s plantar tissues.
      • Pseudomonas is associated with deep space infection, osteochondritis, and osteomyelitis.
    • Ciprofloxacin is typically recommended as empiric antibiotic coverage for this type of injury; however, we have also been taught to avoid fluoroquinolones in children due to the risk of cartilage and joint adverse events.
      • What we know:
        • Fluoroquinolones can lead to adverse musculoskeletal events in children AND adults.
          • Arthritis and Arthralgia most commonly.  Typically it is transient.
          • Tendinopathy is more likely to occur in older patients, patients taking corticosteroids, and patients with renal disease.
        • Fluoroquinolones can be used effectively in children (some examples below):
          • Anthrax
          • UTI due to Pseudomonas.
          • Chronic suppurative otitis media
          • Osteomyelitis or osteochondritis due to Pseudomonas.
          • Pulmonary disease exacerbation in pt with cystic fibrosis colonized with Pseudomonas.
          • Gram-negative infection in immunocompromised host.
          • Multi-drug resistant Shigella, Salmonella, Vibrio, or C. jejuni.
        • There use leads to increased resistance to them (natural selection wins again). So, it is ideal to not overuse these important medications.

 

  • A Possible Answer:

  1. Evaluate the wound with a high index of suspucion for retained foreign bodies!
    • Xrays can be helpful.
    • Bedside ultrasound can also help detect the FB… and aide in its removal.
  2. Irrigate and cleanse the wound with COPIOUS fluids!!
  3. Don’t forget to update tetanus when needed.
  4. Empiric Antibiotics?
    • Injury <24 hrs ago:
      • The plantar puncture wound that has just occurred can be managed expectantly with good anticipatory guidance and return precautions.
      • For those patients at greater risk for infection (ex, diabetic, immunocompromised, puncture more distal on foot), empiric antibiotics covering Staph and Strep is appropriate.
      • Empiric coverage for Pseudomonas is not generally needed, as long as you can ensure follow-up in 24-48hrs.
    • Injury occurred 24 – 72 hrs ago:
      • For those who were not started on antibiotics and have worsened over the first 24-48hrs, empiric coverage for Staph and Strep should be started.
      • If the injury occurred while the patient was wearing footwear, coverage for Pseudomonas can be considered.
    • Injury occurred >72 hrs ago:
      • If the patient has signs of infection this far out from the injury, a high index of suspicion should be had for deep infection and/or foreign body.
      • Empiric coverage for Pseudomonas would be appropriate.

       

     

The notion that all plantar puncture wounds should be started on Cipro for possible Pseudomonas infection is likely an overstatement and can lead to unnecessary use of a valuable antibiotic.  Make sure to explain the concern to the patient, but if it has only been a day, you should spend more time irrigating the wound than determining whether it is safe to administer Cipro.

 

Committee on Infectious Diseases. The Use of Systemic Fluoroquinolones. Pediatrics 2006; 118; 1287.

Sean Fox

I enjoy taking care of patients and I finding it endlessly rewarding to help train others to do the same. I trained at the Combined Emergency Medicine and Pediatrics residency program at University of Maryland, where I had the tremendous fortune of learning from world renown educators and clinicians. Now I have the unbelievable honor of working with an unbelievably gifted group of practitioners at Carolinas Medical Center. I strive every day to inspire my residents as much as they inspire me.

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7 Responses

  1. Monica says:

    My 11 year old stepped on a rusty carpet nail in our basement last night. Small puncture wound that we cleaned with soap and water. He was barefoot. Went to Dr today to get tetnus shot and she cleaned it again and xray showed nothing still in foot. She prescribed Keflex and cipro as a preventative. My concern is with the potential side effects of the cipro. He is overall healthy otherwise. What are your thoughts?

    • Sean Fox says:

      Monica,
      Obviously, I cannot comment specifically about any individual or give out medical advice to any individual.

      What I would recommend is that you have an honest conversation with your child’s doctor and discuss your concerns.

      Thank you,
      sean

  2. simeon godick RPAC MPAS says:

    What would be the appropriate pediatric dosing of cipro?

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