From the Guidelines
Deep puncture wounds to the foot require prompt medical attention due to their high risk of infection and complications, and management should prioritize preventing morbidity, mortality, and improving quality of life. The most recent and highest quality study 1 emphasizes the importance of early intervention and proper wound care to prevent infections and promote healing. Common complications of deep puncture wounds to the foot include:
- Infections (particularly from Pseudomonas in nail punctures)
- Foreign body retention
- Cellulitis
- Abscess formation
- Osteomyelitis
- Rarely, necrotizing fasciitis
Management begins with thorough cleaning of the wound using soap and water, followed by application of antiseptic solution. Tetanus prophylaxis should be administered if vaccination is not current (within 5-10 years) 1. Antibiotic therapy is often necessary, with options including amoxicillin-clavulanate 875/125 mg twice daily, cephalexin 500 mg four times daily, or ciprofloxacin 500 mg twice daily for 7-10 days, especially for Pseudomonas coverage in nail punctures. Deep wounds may require surgical exploration to remove foreign bodies and debride necrotic tissue, as recommended by the 2016 IWGDF guidance on the diagnosis and management of foot infections in persons with diabetes 1.
Surgical intervention should be considered for patients with severe infections, and the goal of surgical treatment is to drain any deep pus and minimize tissue necrosis by decompressing foot compartments and removing devitalized and infected tissue. Patients should elevate the foot, apply ice to reduce swelling, and avoid weight-bearing until healing progresses. Warning signs requiring immediate medical attention include increasing pain, redness extending beyond the wound, streaking up the leg, purulent discharge, fever, or inability to bear weight. Diabetic patients require particularly aggressive management due to their higher risk of complications from impaired wound healing and decreased sensation, as highlighted in the 2012 Infectious Diseases Society of America clinical practice guideline for the diagnosis and treatment of diabetic foot infections 1.
In terms of antibiotic therapy, the choice of agent and duration of treatment should be guided by the severity of the infection and the presence of any underlying conditions, such as diabetes or peripheral vascular disease. The use of topical antimicrobial agents or antimicrobial-impregnated wound dressings may be considered for preventing or treating mild infections, but further research is needed to support their use 1. Overall, the management of deep puncture wounds to the foot requires a comprehensive approach that prioritizes preventing morbidity, mortality, and improving quality of life.
From the Research
Complications of Deep Puncture Wounds to the Foot
- Cellulitis: a common complication of puncture wounds to the foot, which can be prevented with prompt and appropriate care of the wound 2, 3
- Retained foreign bodies: a possible complication if the wound is not properly cleaned and debrided 3
- Osteomyelitis: a serious complication that can occur if the wound becomes infected, particularly with Pseudomonas aeruginosa 4, 5
- Pseudomonas osteochondritis: a complication that can occur in children, which requires thorough surgical debridement and anti-Pseudomonas antibiotic therapy 5
Management of Deep Puncture Wounds to the Foot
- Cleansing the wound: a fundamental step in the treatment of puncture wounds to prevent infection 2
- Debridement of necrotic or devitalized tissue: necessary to prevent infection and promote healing 2, 5
- Tetanus prophylaxis: important to prevent tetanus infection 4
- Antibiotic treatment: may be necessary if the wound becomes infected, particularly with Pseudomonas aeruginosa 4, 5
- Surgical exploration: may be necessary if a foreign body is suspected or if the wound does not heal properly 3
- Radiographs: may be necessary to check for foreign bodies or bone involvement 3
- Aggressive treatment: necessary to reduce the risk of complications and ensure a satisfactory outcome for the patient 6