Management of Nail Puncture Injuries in Emergency Medicine
Nail puncture injuries should be thoroughly irrigated with a large volume of warm or room temperature potable water until there is no foreign matter in the wound, followed by appropriate antibiotic coverage and tetanus prophylaxis if indicated. 1
Initial Assessment
- Evaluate the location of the puncture wound - wounds in zone 1 (plantar surface of the foot) have a 97% higher risk of developing pyarthrosis or osteomyelitis 2
- Assess for signs of infection including increased pain, redness, swelling, or purulent drainage 3, 4
- Determine the time elapsed since injury - longer duration between injury and treatment is associated with poorer outcomes 5
- Identify the type of footwear worn during injury - tennis shoes predispose to Pseudomonas aeruginosa infection 2
- Evaluate for possible foreign body retention, particularly with rubber-soled shoes 5
- Consider ultrasonography if foreign body is suspected - shown to be useful in detecting presence of foreign bodies 5
Treatment Protocol
For Non-Infected Wounds (Early Presentation)
- Thoroughly irrigate the wound with a large volume of warm or room temperature potable water until there is no foreign matter in the wound 1
- Do not apply suction to the wound 1
- Cover the wound with antibiotic ointment and a clean occlusive dressing 1
- Consider tetanus prophylaxis if indicated based on immunization status 3
- For nail puncture wounds through rubber-soled shoes, maintain high suspicion for foreign body retention 5
For Infected Wounds
- Obtain bacterial/viral/fungal cultures if infection is suspected 3, 4
- Initiate appropriate antibiotics with coverage against Staphylococcus aureus and Pseudomonas aeruginosa 3, 6
- For Pseudomonas infections (common in nail puncture wounds), ciprofloxacin has shown effectiveness (750 mg twice daily) following appropriate surgical intervention 6
- Consider daily antiseptic soaks with dilute vinegar (50:50 dilution) or 2% povidone-iodine for 10-15 minutes twice daily 3
- Apply mid to high-potency topical steroid ointment to wound edges twice daily to reduce inflammation 3
Surgical Intervention Indications
- Presence of abscess requiring drainage 7
- Suspected foreign body retention 5
- Deep puncture wounds in zone 1 (plantar surface of the foot) 2
- Signs of bone penetration in any zone 2
- Persistent infection despite appropriate antibiotic therapy 7
- Diabetic patients with puncture wounds (higher risk of complications) 5
Special Considerations
- Diabetic patients have higher risk of treatment failure and should be monitored more closely 5
- Patients with puncture wounds through rubber-soled shoes have higher risk of foreign body retention and Pseudomonas infection 2, 5
- Early surgical intervention for deep puncture wounds in zone 1 may prevent development of osteochondritis 7
- Consider hospital admission for patients with deep puncture wounds in zone 1 or history of bone penetration 2
- Patients treated with antibiotics in the community before hospitalization may have poorer outcomes 5
Follow-up Care
- Monitor for signs of infection including increased pain, redness, swelling, or purulent drainage 3, 4
- For granulation tissue formation, consider silver nitrate application 3
- Reassess wound healing at 2 weeks post-procedure to determine if additional interventions are needed 3
- For patients not admitted to hospital but meeting high-risk criteria, ensure close observation 2