A. Epidemiology

1. 3-5% of all pediatric traumatic injuries
2. Location
   1. More than 50% involve the plantar surface of the foot
   2. Alternate sites: legs, arms, hands
   3. Trunk and head less common
3. Penetrating objects
   1. 90% of plantar wounds caused by nails
   2. Wood, metal, plastic, and glass also common

B. Risk Factors for Complications

1. Greater depth of wound
2. Wound location
3. Type of penetrating object
4. Presence of foreign body
5. Neurologic, vascular, or tendon compromise

C. Infectious Complications

1. Occur in 6-10% of all puncture wounds
2. Increased risk with deep wounds, devitalized tissue, or retained foreign bodies
3. Local wound infections
   1. Presents with warmth, erythema, or persistent pain of wound
   2. Signs typically start within 24 hours of injury
   3. Fever and other systemic symptoms usually absent
   4. Infectious etiology
4. Infectious Agents in Local Wounds
   1. Staphylococcal aureus
   2. Beta-hemolytic streptococci
   3. Anaereobic bacteria
   4. Pasteurella multicoda (animal bite or claw)
5. Osteochondritis
   1. Infection of articular and physeal cartilage
   2. Complicates plantar wounds (particularly forefoot)
   3. Majority of patients wearing tennis sneakers
   4. Presents with prolonged (> 5 days) of symptoms
   5. Infectious etiology
6. Infectious Agents in Osteochondritis
   1. Pseudomonas aeroginosa
   2. Majority of cases
   3. Commonly cultures from tennis shoe foam rubber
   4. Gram positives: ß-hemolytic streptococci, S. aureus
   5. Gram negatives: Klebsiella, Serratia marcescens, Bacteroides melanogenicus, E. coli, Proteus mirabilis, Salmonella typhi
7. Diagnosis of Osteochondritis
   1. Radiograph showing a periosteal reaction or bone or cartilage destruction (late signs)
   2. Bone scan or MRI needed for earlier radiologic diagnosis

D. Clinical Assessment

1. History
   1. Time and mechanism of injury
   2. Degree of contamination
   3. Possibility of retained foreign body (high index of suspicion)
2. Physical examination
   1. Assess distal circulation and motor function
   2. Examine wound thoroughly
3. Radiologic studies
   1. Glass or metal objects seen
   2. Non-radioopaque bodies may create a filling defect
   3. Consider ultrasound or CT as supplemental studies

E. Treatment

1. Clean the wound
   1. Consider local anesthesia
   2. Irrigate with copious saline if dermis is exposed
   3. Avoid high water pressures because it may damage tissue or push bacteria deeper into the wound
   4. Remove foreign material from skin (prevents tattooing)
   5. Blind surgical exploration for retained foreign bodies not indicated
2. Initial antibiotic treatment
   1. Prescribe at first signs of local infection
   2. Initially cephalexin, dicloxacillin, or erythromycin
   3. Re-evaluate for clinical response by 48 hours
3. Persistent symptoms after 4-5 days of therapy
   1. Suggests Pseudomonas aeroginosa infection
   2. Check complete blood count (CBC) and sedimentation rate (ESR)
   3. Evaluate for osteochondritis
   4. Admit for IV anti-pseudomonal therapy
   5. Consider orthopedic referral for surgical debridement
4. Prophylactic antibiotics
   1. Not routinely indicated after a puncture wound
   2. Use for high risk wounds such as bites (animal or human), claw or facial wounds
5. Tetanus vaccination
   1. Determine current immunization status
   2. Repeat if more than 5 years since last vaccination
6. Adjunctive therapy
   1. Rest and elevate the injured extremity
   2. Intermittent warm water soaks

References

1. Baldwin G and Coulbourne M. 1999. Pediatrics in Review. 20(1):21
2. Patzakis M, et. al. 1989. Western J of Med. 150:545