What is the appropriate management for a puncture wound?

Puncture Wound Management

Irrigate the wound thoroughly with copious water or sterile saline, do not close it, administer tetanus prophylaxis based on immunization history, start empiric antibiotics (amoxicillin-clavulanate 875/125 mg twice daily for 3–5 days) for contaminated or high-risk wounds, obtain imaging if foreign body or bone involvement is suspected, and ensure close follow-up within 24 hours. 1, 2, 3

Immediate Wound Assessment and Cleaning

• Irrigate the wound abundantly with warm potable water or sterile saline to remove all visible contaminants, dirt, and debris—this is the single most critical step to prevent infection. 2, 4
• Avoid using antiseptics (hydrogen peroxide, povidone-iodine) for initial irrigation, as they may damage tissue and impair healing; plain water or saline is preferred. 2
• Inspect the wound carefully for depth, location, mechanism of injury (nail, glass, wood, metal), footwear at time of injury, and any visible foreign material. 5, 6
• Do not close puncture wounds primarily—closure dramatically increases infection risk by trapping bacteria and debris deep in the wound tract. 1, 4
• Débride any obviously necrotic or devitalized tissue at the wound margins. 4

Imaging for Foreign Body and Bone Involvement

• Obtain plain radiographs (PA, lateral, oblique views) immediately if there is any suspicion of retained foreign body or bone penetration—radiographs detect metal, stone, glass, and graphite but miss wood and plastic. 7, 1
• If radiographs are negative but clinical suspicion remains high (deep wound, persistent pain, mechanism suggests foreign body), advance to CT with 1 mm slice thickness, which is 5–15 times more sensitive than plain films and can visualize wood as moderately hyperdense. 7, 1
• MRI is the gold standard when osteomyelitis is suspected; a negative MRI effectively rules out bone infection. 7, 1
• Ultrasound may assist in detecting superficial foreign bodies and soft tissue fluid collections but has limited utility for deeper structures. 7

Tetanus Prophylaxis

• Administer tetanus toxoid (Td or Tdap) if more than 5 years have elapsed since the last dose for all contaminated or "dirty" puncture wounds (wounds contaminated with dirt, soil, saliva, feces, or resulting from crushing, burns, or frostbite). 3, 8
• For clean, minor wounds, give tetanus toxoid only if more than 10 years since the last dose. 3, 8
• Administer Tetanus Immune Globulin (TIG) 250 units IM at a separate site if the patient has received fewer than 3 doses of tetanus toxoid (or immunization history is unknown or uncertain) AND the wound is contaminated or high-risk. 3, 8
• Do not give TIG for clean, minor wounds regardless of immunization history. 3, 8
• Patients with unknown vaccination histories should be assumed to have had no previous tetanus toxoid doses. 8

Antibiotic Therapy

• Start empiric amoxicillin-clavulanate 875/125 mg orally twice daily for 3–5 days for all contaminated puncture wounds, wounds with potential bone involvement, or wounds presenting more than 6 hours after injury. 1
• Amoxicillin-clavulanate provides coverage for Staphylococcus aureus, Streptococcus species, anaerobes, and atypical organisms including nontuberculous mycobacteria (NTM) commonly found in soil and shoe material. 1
• Avoid first-generation cephalosporins, macrolides, or clindamycin alone—they lack adequate coverage for the polymicrobial flora and NTM typical of puncture wounds. 1
• If bone involvement (osteomyelitis) is confirmed, extend antibiotic duration to 4–6 weeks and add agents active against gram-negative bacteria and anaerobes. 1
• If septic arthritis develops, treat for 3–4 weeks. 1
• Recognize that NTM infections (especially Mycobacterium marinum, M. fortuitum) can present weeks to months later with chronic granulomatous tenosynovitis, bursitis, and osteomyelitis—maintain high suspicion in wounds contaminated with soil or aquatic environments. 1

Wound Dressing and Local Care

• After irrigation and débridement, cover the wound with antibiotic ointment (e.g., bacitracin, mupirocin) and a clean, non-adherent occlusive dressing to maintain a moist environment and prevent contamination. 2
• Applying ointment to a moist wound is appropriate and promotes optimal healing. 2
• Change dressings daily initially, inspecting for signs of infection (increasing erythema, purulent drainage, warmth, swelling, foul odor). 2
• Elevate the injured extremity above heart level for the first 48–72 hours to minimize swelling and promote healing. 1, 2

Mandatory Follow-Up and Patient Education

• Ensure follow-up within 24 hours (phone call or clinic visit) to monitor for infection progression—puncture wounds can rapidly develop deep space infections, osteomyelitis, or septic arthritis. 1
• Educate patients to return immediately for warning signs: pain disproportionate to injury, increasing swelling, spreading redness, purulent or foul-smelling drainage, fever, chills, or loss of function. 1, 2
• Emphasize that infection may not be apparent for 24–72 hours and can progress rapidly once established. 9, 5

High-Risk Wounds Requiring Aggressive Management

• Puncture wounds of the foot through a shoe carry high risk of Pseudomonas aeruginosa osteochondritis and require particularly close monitoring. 5, 6
• Wounds penetrating joints, tendons, or bone require surgical consultation for possible exploration, irrigation, and débridement. 1, 5
• Wounds in immunocompromised patients (diabetes, peripheral vascular disease, immunosuppression) require lower threshold for hospitalization, IV antibiotics, and surgical intervention. 5, 10
• Consider incision, drainage, and formal exploration for wounds with high contamination, delayed presentation (>24 hours), or clinical signs of deep infection. 4, 10

Common Pitfalls to Avoid

• Never close a puncture wound—this traps bacteria and foreign material deep in the tissue, dramatically increasing infection risk. 1, 4
• Do not rely on a negative plain radiograph to exclude foreign bodies—wood, plastic, and some glass are radiolucent and require CT or ultrasound for detection. 7, 1
• Do not use inadequate antibiotic coverage (e.g., cephalexin alone)—puncture wounds require broad-spectrum coverage including NTM activity. 1
• Do not underestimate the risk of osteomyelitis in bone-penetrating wounds—these require prolonged antibiotic therapy (4–6 weeks) if infection develops. 1, 5
• Do not discharge patients without explicit instructions to return for worsening symptoms and mandatory 24-hour follow-up. 1