What is the recommended treatment for a pediatric patient with a puncture wound through a shoe?

Management of Pediatric Puncture Wounds Through Shoes

For pediatric puncture wounds through shoes, thorough wound cleansing, debridement, and appropriate antibiotic therapy covering Pseudomonas aeruginosa is essential, as these injuries carry a high risk of deep tissue infection including osteochondritis that may require surgical intervention. 1, 2

Initial Assessment and Management

• Puncture wounds through shoes require immediate attention as they are at high risk for infection, particularly from Pseudomonas aeruginosa which can be harbored in shoe materials 1, 3
• Thoroughly cleanse and debride the wound, removing any foreign material or necrotic tissue 4
• Obtain appropriate specimens for culture from infected wounds prior to starting antibiotics by scraping with a sterile scalpel or dermal curette from the base of a debrided wound 4
• Do not culture clinically uninfected wounds unless for specific epidemiological purposes 4

Antibiotic Therapy

• For clinically infected wounds, empiric antibiotic therapy should be started promptly, as delay >3 hours increases infection risk 4
• Antibiotic selection should cover Pseudomonas aeruginosa, which is frequently isolated from puncture wounds through shoes 1, 2, 3
• Recommended empiric therapy:
  • For mild to moderate infections: An oral fluoroquinolone (if age-appropriate) or parenteral anti-pseudomonal agent 4
  • For severe infections: Parenteral anti-pseudomonal therapy 4

Special Considerations for Fluoroquinolones in Children

• While fluoroquinolones are not routinely recommended in children, their use may be justified in special circumstances 4
• The use of fluoroquinolones in children may be appropriate for "osteomyelitis or osteochondritis caused by P. aeruginosa (not for prophylaxis of nail puncture wounds to the foot)" 4
• Consider the risks and benefits carefully before prescribing fluoroquinolones to pediatric patients 4

Warning Signs of Complications

• Delayed presentation (>24-36 hours) is a significant marker for deep-seated infection 5
• Be vigilant for signs of Pseudomonas osteochondritis or septic arthritis, which may present with minimal initial symptoms 1, 6
• Failure to improve with initial antibiotic therapy suggests possible osteomyelitis, septic arthritis, or retained foreign body 2, 5

Surgical Management

• Seek surgical consultation for:
  • Deep abscess formation
  • Evidence of osteomyelitis or septic arthritis
  • Presence of retained foreign body
  • Failure to respond to appropriate antibiotic therapy 4, 2
• Thorough surgical debridement is essential for eradication of Pseudomonas osteochondritis 2, 3
• Following adequate surgical debridement, 7-14 days of anti-pseudomonal antibiotic therapy is typically sufficient 2, 3

Duration of Therapy

• For superficial infections without complications: 1-2 weeks of appropriate antibiotic therapy 4
• For osteochondritis or septic arthritis: After thorough surgical debridement, 7-14 days of anti-pseudomonal antibiotics 2, 3
• Continue antibiotic therapy until there is evidence that the infection has resolved, but not necessarily until the wound has completely healed 4

Follow-up Care

• Close follow-up is essential to ensure resolution of infection 4
• Consider imaging studies (X-ray, bone scan, or CT) for patients with suspected deep infection or retained foreign body 5
• Monitor for residual radiologic sequelae, though most patients become asymptomatic with appropriate treatment 5

Remember that puncture wounds through shoes in children often have delayed presentation and diagnosis due to minimal initial symptoms, but can lead to serious complications including osteomyelitis and septic arthritis if not properly managed 1, 6.