What is the management for a puncture wound to the wrist?

Management of Puncture Wounds to the Wrist

For puncture wounds to the wrist, thorough irrigation with saline or clean tap water (100-1000 mL), careful wound assessment for foreign bodies, and appropriate wound dressing are essential for optimal outcomes. 1

Initial Assessment and Management

Immediate Care

• Assess for neurovascular compromise (check sensation, capillary refill, and motor function)
• Control bleeding with direct pressure
• Provide appropriate pain relief before wound management 1
• Thoroughly irrigate with saline (100-1000 mL) or clean tap water 1
  • Pressure irrigation is more effective than standard irrigation for contaminated wounds

Wound Examination

• Evaluate for potential foreign bodies
• Initial radiographs are usually appropriate for penetrating trauma to the wrist 2
• If foreign body is suspected and initial radiographs are negative:
  • Ultrasound of the area is recommended (high sensitivity for superficial foreign bodies) 2
  • CT without IV contrast is an equivalent alternative (63% sensitivity, 98% specificity for radiopaque foreign bodies) 2

Wound Care Protocol

Cleaning and Debridement

• Irrigate thoroughly to reduce bacterial load
• Handle skin carefully to minimize epidermal detachment 2
• Debride any necrotic tissue if present 1
• For contaminated wounds, consider antimicrobial soaks 1

Dressing Application

1. Apply small amount of antibiotic ointment to wound 1
2. Cover with non-adherent dressing (e.g., Mepitel™ or Telfa™) 1
3. Secure with soft bandages or tubular bandage to avoid adhesive tapes 2
4. Avoid adhesive dressings directly on skin to prevent further trauma 2

Antibiotic Management

Prophylactic Antibiotics

• For uncomplicated, clean puncture wounds: prophylactic antibiotics are not routinely recommended 1, 3
• For high-risk wounds (deep penetration, contaminated, delayed presentation >24 hours):
  • Amoxicillin-clavulanate 875/125 mg twice daily for 3-5 days 1

Established Infections

• For mild superficial infections: topical antimicrobials 1
• For mild to moderate deep infections: oral antibiotics 1
• For severe infections: parenteral antibiotics and surgical consultation 1

Special Considerations

Tetanus Prophylaxis

• Administer tetanus toxoid if not received within the last 10 years for clean wounds 2
• For contaminated wounds, administer if >5 years since last dose 2
• Complete primary series if not previously completed 2

Foreign Body Management

• If foreign body is suspected, imaging is essential as described above
• Foreign body removal may require ultrasound guidance 2
• Surgical consultation for deep or complex foreign bodies

High-Risk Features Requiring Urgent Attention

• Signs of infection (temperature >38.5°C, heart rate >110 beats/minute, erythema >5 cm) 1
• Rapid progression of swelling or pain
• Crepitus or gas in tissues (may indicate gas gangrene, which can progress rapidly) 4
• Involvement of tendon sheaths (may indicate pyogenic flexor tenosynovitis) 5

Follow-up Care

• Instruct patient to keep wound clean and dry
• Educate on signs of infection: increasing redness, swelling, warmth, purulent drainage, increasing pain, fever 1
• Schedule follow-up within 3-5 days, sooner if symptoms worsen 1
• For sutured wounds, arrange suture removal within 10-14 days 1

Complications to Monitor

• Infection (superficial or deep)
• Tenosynovitis (especially with punctures over flexor tendon sheaths) 5, 6
• Retained foreign bodies
• Neurovascular compromise
• Rare but serious: necrotizing infections or gas gangrene 4

By following this systematic approach to puncture wound management, clinicians can minimize complications and optimize healing outcomes.