A Review of Puncture Injury Protocols and Tetanus Prophylaxis
Puncture wounds caused by sharp objects are common, especially in the feet. These injuries are usually simple, but if not treated appropriately and in a timely manner, they can be complicated and be limb- and life-threatening. Here, we review the literature and discuss the protocols for pedal puncture wounds and tetanus prophylaxis.
Although puncture wounds are common, their exact incidence is difficult to decipher. People who sustain this injury often do not seek medical attention. In a cross-sectional study, an analysis of 200 patient surveys in the emergency department revealed that approximately 44% (88 respondents) had sustained at least one plantar puncture wound, with a total of 156 reported wounds with an 11% infection rate.1 Nearly half of these wounds (77) were not evaluated by a doctor.1
One prospective uncontrolled case series reviewed 63 patients who sustained uncomplicated plantar puncture wounds and monitored patients over time via telephone.2 This study found a complication rate of 11.9%, consisting of 5 infections and 2 retained foreign bodies. Generally, a puncture wound left untreated greater than 6 hours is more likely to house infectious organisms and a wound left untreated greater than 48 hours is more likely to develop a complication.3
Risk Factors for Infection: What the Evidence Reveals
Carefully ascertaining a history is important in appropriately managing puncture wounds and identifying risk factors of infection. Knowledge of risk factors for infections in puncture wounds can help guide the history and physical examination.
Diabetes mellitus is a major risk factor for infections following a puncture injury. In a retrospective study of 114 hospitalized patients with puncture wounds, authors found diabetes to be associated with subsequent osteomyelitis and patients with diabetes were more likely to require multiple operations and an eventual amputation.4 The risk of infection after a puncture wound increases if the site is in the forefoot or when the patient is wearing shoes at the time of injury. One study reviewed 76 adults with diabetes admitted for a foot infection after a puncture and found forefoot puncture wounds in patients who wore shoes at the time of puncture were more likely to develop osteomyelitis.5 Moreover, osteomyelitis from infected puncture injuries is associated with Staphylococcus aureus and polymicrobial infections in patients with diabetes while Pseudomonas was the most common cause of osteomyelitis in patients without diabetes.6 When reviewing the risk factors for amputation between patients with and without diabetes who had incision and drainages for infected puncture wounds of the foot, patients with diabetes were 5 times more likely to require multiple operations and 46 times more likely to undergo an amputation compared to those without diabetes. Patients with diabetes who underwent an amputation had a higher prevalence of vascular disease, nephropathy, and neuropathy compared to nonamputee patients with diabetes. Additionally, the time from injury to surgery was longer for patients with diabetes compared to patients without diabetes.7
Irrespective of diabetes, one study compared 36 inpatients and 34 outpatients with nail puncture wounds of the foot. This group divided the foot into 3 zones. Zone 1 extends from the ends of the toes to the metatarsal necks. Zone 2 includes the anatomic landmarks between the metatarsal necks and the distal aspect of the calcaneus. Zone 3 includes the plantar calcaneus. This group found that 35 inpatients (97%) had deep puncture wounds in zone 1 (toes to metatarsal necks), compared to 6 outpatients (18%) in this zone. Moreover, this study found that wearing tennis shoes during the injury predisposed patients to Pseudomonas aeruginosa infections.8
Another study reviewed 96 patients with nail punctures through rubber-soled shoes. Thirty-six (37.5%) had conservative treatment while 60 (62.5%) had surgical treatment.
Fifteen of the 60 surgical patients had foreign body extraction during the operation. The surgical group had a longer duration of time from injury to hospital admission compared to the conservative group (5 days vs 2.7 days, respectively).9
Based on laceration data, likely risk factors for infection after a puncture injury are bigger wounds, increased age, and retained foreign bodies.10 A cross-sectional study reviewed 5521 consecutive patients with traumatic lacerations.10 Increased laceration width, age, and the presence of a foreign body were associated with a higher likelihood of wound infection. Again, a history of diabetes mellitus was also associated with infection.10 Researchers found similar results in a multicenter study of 2663 patients with traumatic lacerations and found that patients with diabetes, contaminated wounds, and lacerations greater than 5 cm had no significant difference between infection rates of lacerations and the length of time from injury to wound closure.11
Although it is beyond the scope of this review, it’s important to mention that it is possible to develop infection from puncture wounds with water exposure. The risks of infection from highest to lowest risk are from fresh waters (ponds, small lakes), flowing fresh water (rivers, large lakes), brackish water (found where sea water and freshwater meet), sea water, and well-regulated treated waters (swimming pools, hot tubs).12–14 Individuals at risk for soft tissue infections following water exposure include recreational swimmers, boaters, fisherman, flood victims and rescue workers, people undergoing leech therapy, patients with underlying liver disease and immunosuppression, and intravenous drug users.15–22 These types of infections can be complex and quickly escalate. Therefore, we recommend consulting infectious disease colleagues.
A Guide to Evaluating Puncture Wounds
History and physical. Clinicians should specifically include the following information while interviewing a patient with a puncture wound:
• Description of the penetrating object (size, shape, attached to anything, etc.)
• Depth of penetration
• Scene of injury
• Footwear at time of injury
• Time since injury
• Presence of retained foreign body
• Medical history
• Tetanus prophylaxis history
• Water exposure
Imaging. Imaging can be helpful after a puncture wound to identify retained foreign bodies and evaluate for deep infections.
Take standard radiographs of the foot to identify retained radiolucent foreign bodies or involvement of underlying osseous structures; however, these radiographs may be limited in identifying small pieces of glass, wood, or rubber. In a case series that sought to identify the role of ultrasound in identifying wooden foreign bodies in the foot, researchers found that of the 10 patients who had retained wooden foreign bodies, plain radiographs did not identify a single foreign body.23 Therefore, advanced imaging may be necessary.24
Magnetic resonance imaging (MRI) may be helpful in developing a treatment plan. Identifying small foreign bodies, especially linear in morphology, can be difficult as they can be mistaken for tendons or dense collagenous structures; however, MRI can be helpful in identifying abscesses and osteomyelitis, which may indirectly assist in identifying retained non-metallic foreign bodies.
Computed tomography (CT) scans can be helpful in evaluating retained foreign bodies. When dry wood enters the body through a puncture, it is predominantly filled with air, which can mimic a gas collection.25 Within a week, the wood subsequently absorbs surrounding blood products and exudates, increasing its attenuation.26 Further alterations in attenuation can be affected by surface coating such as sealant or paint, assisting in the diagnosis.27 One should consider that CT scans are generally readily available, faster to perform, and less expensive than MRIs.
The role of ultrasound in detecting foreign bodies in the foot is variable. Studies have reported ultrasound to have a specificity of 95% but sensitivity of 43.2% for detecting foreign bodies, likely because of the small size of the object, indicating one cannot use ultrasound to rule out retained foreign bodies but it can be helpful in characterizing its size and location.28 However, an earlier study of 20 patients with possible wooden foreign bodies in their feet had ultrasonography and found a 100% sensitivity in detecting the wooden foreign bodies.23 With such varying reports, it’s likely that there is a component of user error and size dependence. There may be a larger role in ultrasound to identify or triangulate foreign bodies in the future. These machines are readily available in the emergency department, have minimal associated cost, and one can use them readily at bedside during the patient encounter. As such, pending resource availability and urgency, ultrasound has some utility in select scenarios.
What You Should Know About Laboratory Testing for Tetanus
The history and physical exam guides most of the laboratory testing. If there are cardinal signs of inflammation present, then a complete blood cell count (CBC), metabolic panel, and other inflammatory markers such as C-reactive protein (CRP) and erythrocyte sedimentation rate (ESR) may be helpful in determining a systemic response, including monitoring vital signs.
Additionally, if there is high suspicion of infection, one can take and monitor blood cultures. Blood culture results can take a few days, so if the patient is not exhibiting a systemic reaction to the puncture wound/infection, one can discharge the patient with oral antibiotics and closely monitor them. If the blood cultures do indeed come back positive, one can call the patient back to the hospital for a formal reassessment and possible intervention.
How to Treat Puncture Wounds
When assessing puncture injuries for treatment options, identify retained foreign bodies. If the puncture injury is superficial, has no retained foreign bodies, and does not exhibit signs of infection, it is likely one can treat the injury with local wound care. If there is concern for a mild infection that is yet manifested clinically, the patient can start on empiric antibiotics.
One study retrospectively reviewed 80 patients (28 children, 52 adults) who sustained pedal puncture injuries.29 Patients who presented with an infection and received antibiotics did not present with signs of infection after follow-up; however, patients who presented within 24 hours of the injury were likely not to receive antibiotics, likely because an infection may have been brewing but the patient did not yet mount an inflammatory response. These earlier-presenting patients were likely not to be treated with antibiotics, but were more likely to develop an infection at follow-up. Moreover, when the earlier-presenting patients took oral antibiotics, they were less likely to present with an infection at follow-up.
Fortunately, the University of Texas puncture wound scoring system can help guide treatment. This treatment algorithm stratifies by age of the wound, wound morphology, depth, whether patients wore footwear during injury, and osseous involvement on radiographs.30 If the score is less than 5, the treatment is local wound care and observation. If the score is 5 through 8, the treatment includes local wound care, incision and drainage, exploration for foreign bodies, and a drain placement. If the score is greater than 9, the system highly recommends incision and drainage, wound lavage, hospitalization, and parenteral antibiotics.30
When taking cultures, deep wound and tissue cultures are preferable compared to superficial wound cultures. If there is suspected osseous involvement, obtain bone culture and pathology to rule out osteomyelitis. If removing a retained foreign body, send it for culture and pathology.
Insights on Tetanus Prophylaxis and Treatment
Tetanus is a potentially fatal illness caused by a neurotoxin tetanospasmin produced by Clostridium tetani bacteria, typically entering the body through contaminated wounds. The neurotoxin binds to peripheral motor neurons and sensory neurons and is transported retro-axonally to the spinal cord. The neurotoxin disrupts nerve signaling, leading to muscle stiffness and spasms, ultimately resulting in paralysis.31 Once the Clostridium tetani bacterium enters the body the incubation period is approximately 8 days but can range from 3 to 21 days.
While antibiotics are universally recommended for tetanus treatment, their role is likely minor. Adequate wound debridement is crucial for eradicating C tetani, as highlighted by a study where antimicrobial therapy failed to clear the bacteria in severe tetanus cases without proper debridement.32 Metronidazole, administered intravenously at a dose of 500 mg every 6 to 8 hours, is the preferred medication for treating tetanus. However, penicillin G, given intravenously at a dose of 2 to 4 million units every 4 to 6 hours, is also a safe and effective option. An alternative agent is doxycycline (100 mg every 12 hours); other agents with activity against C tetani are macrolides, clindamycin, vancomycin, and chloramphenicol.33
Tetanus, first described in Egypt over 3000 years ago, persists as a significant health issue globally despite available immunizations since the late 19th century.34 With 800,000 to 1 million annual deaths from tetanus, primarily in Africa and Southeast Asia, incomplete vaccination coverage and issues with vaccine quality contribute to its continued prevalence in 90 countries.
The mainstay vaccination method is via tetanus toxoid. Tetanus toxoid is combined with diphtheria and pertussis in vaccines such as DTaP, DTP, Tdap, Td, and DT. The Advisory Committee on Immunization Practices (ACIP) recommends children receive DTaP or DT at 2, 4, and 6 months, with additional doses at 15–18 months and 4–6 years.35 At age 11 or 12, children should get a Tdap booster, followed by a booster every 10 years. For adults, ACIP recommends a Td or Tdap booster every 10 years, with at least one Tdap dose after age 19. Unvaccinated adults receive a series of 3 doses: one initially, a second 4 weeks later, and a third 6–12 months after the second, with at least one Tdap dose. Boosters are recommended every 10 years due to waning immunity. In the instance that a patient who has not been previously vaccinated or the medical history is obscure the patient may also require a tetanus immune globulin shot. This is because the booster shot alone does not provide immediate immunity. Tetanus immune globulin is an antitoxin that neutralizes the tetanus toxin, offering temporary protection until your immune system responds to the booster.35
In Summary
When managing patients with acute or subacute wounds, a thorough medical history and vaccination history are required to adequately decrease the risk of a tetanus infection. Adequate medical history can guide overall treatments, including a history of shoe gear worn during the traumatic puncture. Identification of foreign bodies through physical exam and imaging, wound care strategies with potential debridement and washouts, medical management with antibiotics if needed, and vaccination in the event of potential exposure are necessary as a standard of care.
Dr. Cheung is the podiatric surgery chief resident at Yale New Haven Hospital in New Haven, CT and a member of the American Podiatric Medical Association (APMA) Clinical Practice Advisory Committee.
Dr. Stallings is a second-year podiatric surgery resident at Yale New Haven Hospital in New Haven, CT.
Dr. Gazes is a Fellow of the American College of Foot and Ankle Surgeons, Fellow of the American College of Podiatric Medicine, Clerkship Director and Assistant Program Director for the Yale Podiatric Foot and Ankle Surgery Residency Program, Associate Fellowship Program Director for the Yale Chronic Wound Care and Regenerative Medicine Fellowship, and Assistant Clinical Professor in the Department of Medicine at the Yale School of Medicine.
Published in partnership with the American Podiatric Medical Association.
References
1. Weber EJ. Plantar puncture wounds: a survey to determine the incidence of infection. J Accid Emerg Med. 1996;13(4):274–277.
2. Schwab RA, Powers RD. Conservative therapy of plantar puncture wounds. J Emerg Med. 1995;13(3):291–295.
3. Chisholm CD, Schlesser JF. Plantar puncture wounds: controversies and treatment recommendations. Ann Emerg Med. 1989;18(12):1352–1357.
4. Truong DH, Johnson MJ, Crisologo PA, Wukich DK, Bhavan K, La Fontaine J, et al. Outcomes of foot infections secondary to puncture injuries in patients with and without diabetes. J Foot Ankle Surg. 2019;58(6):1064–1066.
5. Lavery LA, Harkless LB, Ashry HR, Felder-Johnson K. Infected puncture wounds in adults with diabetes: risk factors for osteomyelitis. J Foot Ankle Surg. 1994;33(6):561–566.
6. Lavery LA, Walker SC, Harkless LB, Felder-Johnson K. Infected puncture wounds in diabetic and nondiabetic adults. Diabetes Care. 1995;18(12):1588–1591.
7. Armstrong DG, Lavery LA, Quebedeaux TL, Walker SC. Surgical morbidity and the risk of amputation due to infected puncture wounds in diabetic versus nondiabetic adults. South Med J. 1997;90(4):384–389.
8. Patzakis MJ, Wilkins J, Brien WW, Carter VS. Wound site as a predictor of complications following deep nail punctures to the foot. West J Med. 1989;150(5):545–547.
9. Rubin G, Chezar A, Raz R, Rozen N. Nail puncture wound through a rubber-soled shoe: a retrospective study of 96 adult patients. J Foot Ankle Surg. 2010;49(5):421–425.
10. Hollander JE, Singer AJ, Valentine SM, Shofer FS. Risk factors for infection in patients with traumatic lacerations. Acad Emerg Med. 2001;8(7):716–720.
11. Quinn JV, Polevoi SK, Kohn MA. Traumatic lacerations: what are the risks for infection and has the “golden period” of laceration care disappeared? Emerg Med J. 2014;31(2):96–100.
12. Diaz JH, Lopez FA. Skin, soft tissue and systemic bacterial infections following aquatic injuries and exposures. Am J Med Sci. 2015;349(3):269–275.
13. Diaz JH. Skin and soft tissue infections following marine injuries and exposures in travelers. J Travel Med. 2014;21(3):207–213.
14. Bourque DL, Vinetz JM. Illnesses associated with freshwater recreation during international travel. Curr Infect Dis Rep. 2018;20(7):19.
15. Baddour LM. Extraintestinal Aeromonas infections—looking for Mr. Sandbar. Mayo Clin Proc. 1992;67(5):496-498.
16. Tacket CO, Brenner F, Blake PA. Clinical features and an epidemiological study of Vibrio vulnificus infections. J Infect Dis. 1984;149(4):558–561.
17. Levine WC, Griffin PM. Vibrio infections on the Gulf Coast: results of first year of regional surveillance. Gulf Coast Vibrio Working Group. J Infect Dis. 1993;167(2):479–483.
18. Czachor JS. Unusual aspects of bacterial water-borne illnesses. Am Fam Physician. 1992;46(3):797–804.
19. Janda JM, Abbott SL. Infections associated with the genus Edwardsiella: the role of Edwardsiella tarda in human disease. Clin Infect Dis. 1993;17(4):742–748.
20. Chambers HF. Skin and soft tissue infections in persons who inject drugs. Infect Dis Clin North Am. 2021;35(1):169–181.
21. Harris M, Scott J, Hope V, Wright T, McGowan C, Ciccarone D. Navigating environmental constraints to injection preparation: the use of saliva and other alternatives to sterile water among unstably housed PWID in London. Harm Reduct J. 2020;17(1):24.
22. Baltes A, Akhtar W, Birstler J, Olson-Streed H, Eagen K, Seal D, et al. Predictors of skin and soft tissue infections among sample of rural residents who inject drugs. Harm Reduct J. 2020;17(1):96.
23. Rockett MS, Gentile SC, Gudas CJ, Brage ME, Zygmunt KH. The use of ultrasonography for the detection of retained wooden foreign bodies in the foot. J Foot Ankle Surg. 1995;34(5):478–84; discussion 510–1.
24. Peterson JJ, Bancroft LW, Kransdorf MJ. Wooden foreign bodies: imaging appearance. AJR Am J Roentgenol. 2002;178(3):557–562.
25. Ho VT, McGuckin JF Jr, Smergel EM. Intraorbital wooden foreign body: CT and MR appearance. AJNR Am J Neuroradiol. 1996;17(1):134–136.
26. Ginsberg LE, Williams DW 3rd, Mathews VP. CT in penetrating craniocervical injury by wooden foreign bodies: reminder of a pitfall. AJNR Am J Neuroradiol. 1993;14(4):892–895.
27. McGuckin JF Jr, Akhtar N, Ho VT, Smergel EM, Kubacki EJ, Villafana T. CT and MR evaluation of a wooden foreign body in an in vitro model of the orbit. AJNR Am J Neuroradiol. 1996;17(1):129–133.
28. Arveladze S, Schermann H, Maliarov A, Rubin G. Nail puncture wound through a rubber-soled shoe: should we take every patient to the operating room? J Foot Ankle Surg. 2022;61(3):479–481.
29. Pennycook A, Makower R, O’Donnell AM. Puncture wounds of the foot: can infective complications be avoided? J R Soc Med. 1994;87(10):581–583.
30. Krych SM, Lavery LA. Puncture wounds and foreign body reactions. Clin Podiatr Med Surg. 1990;7(4):725–731.
31. Megighian A, Pirazzini M, Fabris F, Rossetto O, Montecucco C. Tetanus and tetanus neurotoxin: From peripheral uptake to central nervous tissue targets. J Neurochem. 2021;158(6):1244–1253.
32. Campbell JI, Lam TMY, Huynh TL, et al. Microbiologic characterization and antimicrobial susceptibility of Clostridium tetani isolated from wounds of patients with clinically diagnosed tetanus. Am J Trop Med Hyg. 2009;80(5):827–831.
33. Afshar M, Raju M, Ansell D, Bleck TP. Narrative review: tetanus-a health threat after natural disasters in developing countries. Ann Intern Med. 2011;154(5):329–335.
34. Dietz V, Milstien JB, van Loon F, Cochi S, Bennett J. Performance and potency of tetanus toxoid: implications for eliminating neonatal tetanus. Bull World Health Organ. 1996;74(6):619–628.
35. Centers for Disease Control and Prevention. DTaP/Tdap/Td ACIP Vaccine Recommendations.
