- Email: [email protected]
Prophylactic surgical debridement of foot punctures in 146 children. A year's practice with a review of the literature
Foot and Ankle Surgery 9 (2003) 123–127 www.elsevier.com/locate/fas
Prophylactic surgical debridement of foot punctures in 146 children. A year’s practice with a review of the literature K.R. Sharpe*, G. Lamb, A. Bass, C.E. Bruce Department of Trauma and Orthopaedics, Royal Liverpool Children’s NHS Trust, Eaton Road, Liverpool, UK
Abstract We looked at a year’s experience of treating foot puncture injuries in a child population. There were 196 possible children identified from the theatre records. Of these, 146 had a history of a foot puncture injury. There were 111 boys and 35 girls ranging from two to fifteen years and a mean age of nine. There were two peaks at ten and thirteen. These injuries most frequently in the summer and were mostly as a result of a nail puncturing a training shoe. The majority were seen within 24 h of their injury and had their debridement within 24 h of their referral. Eleven per cent of children had a foreign body in the wound. Very few cases were discharged without prophylactic antibiotics but the most frequently used preparation had no anti pseudomonal properties. There was a 1.7% infection rate. There were no pseudomonas infections—only staphylococcus. q 2003 Elsevier Science Ltd. All rights reserved. Keywords: Foot punctures; Antibiotics; Pseudomonas
1. Introduction At the Royal Liverpool Children’s NHS Trust Hospital (Alder Hey Hospital) significant numbers of children are referred to the orthopaedic department with puncture wounds to the foot, most often through the sole of a training type shoe. It is well recognised that foot puncture wounds are susceptible to infection and may be especially vulnerable to infection with pseudomonas aeruginosa, which is a common inhabitant of footwear insoles. The potential for pseudomonas is of concern because the organism can cause significant destructive infection that can be difficult to eradicate [3,6]. Infection with pseudomonas has been especially associated with puncture injuries through the sole of training type shoes at the time of injury [4]. In light of the infection risk it is our current and longstanding practice to formally debride and wash out all puncture wounds under a general anaesthetic and the wound left open to heal by secondary intention. A course of oral antibiotics is prescribed and patients are routinely reviewed * Corresponding author. Address: 29, Boundary Road, West Kirby, Wirral, CH48 1LE UK. Tel.: þ 44-151-625-4061/07770-785-871. E-mail address: [email protected] (K.R. Sharpe).
at least once in the outpatient department after one to two weeks. Because this practice expends considerable time and resources, we were anxious to determine its necessity. The purpose of this study was to determine whether this policy has resulted in a lower infection rate in comparison with other reported studies. Our further aim was to determine whether we could identify particular subgroups of patients who might be especially vulnerable to infection, in terms of the site and nature of the puncture wound and would therefore benefit from this more aggressive policy.
2. Methods This is a retrospective study reviewing the theatre records over a twelve-month period between1st October 1997 and 30th September 1998. All patients who had undergone debridement of a foot puncture wound were included and the medical notes reviewed to collect the site and circumstances of the wound, the interval from injury to operation, the details of the operative record and the follow notes specifically to determine the rate of both early and late infection. Patients were excluded from the study if the injury was recorded to be anything other than a true puncture wound.
1268-7731/03/$ - see front matter q 2003 Elsevier Science Ltd. All rights reserved. doi:10.1016/S1268-7731(03)00042-0
124
K.R. Sharpe et al. / Foot and Ankle Surgery 9 (2003) 123–127
Chart 1.
3. Results One hundred and sixty children were identified from the theatre records of which only 146 had sustained a true puncture wound. The remaining 14 patients had nonpuncturing wounds. None of the patients had diabetes
mellitus or any other medical condition predisposing to infection The demographic details of the included patients are illustrated in Charts 1 and 2. Seventy six percent of patients were boys. The mean age was 9 years and most patients presented during the summer peaking in July. On average in
Chart 2.
K.R. Sharpe et al. / Foot and Ankle Surgery 9 (2003) 123–127 Table 1 Foot wear and item causing puncture wound
Trainers Shoes/Boots Slippers Socks Bare foot
Nail
Glass
Pin/Needle
Other
116 5 2 0 0
6 1 0 1 5
0 0 0 1 6
2 0 0 0 1
Table 2 Time distribution of treatment events of puncture wounds No. presenting ,1 Presentation to Referral to surgery Injury to day post injury referral (days) range (days) surgery (days) {mean} {mean} {mean} 138
0-14 {0.45}
0-3 {0.00}
0-14 {1.05}
the busiest month there was a foot puncture taken to theatre at least once a day. The puncture wounds involved penetration of a training shoe in the majority of cases (86%), with injuries to bare feet next most common (, 1%). The object causing the puncture was a nail in 84% of cases. The remaining cases were as a result of having stood on a number of other items as shown in Table 1. Ninety five percent of children were seen and referred within 24 h of their injury. Ninety seven percent of patients underwent surgical debridement within 24 h of their referral. There were a minority of late presenting cases, eight (5%) in number (Tables 2 and 3). Only simple debridement and washout was required in the majority of cases but 16 children (11%) also required the removal of foreign material. Eleven of these foreign bodies were clinically visible penetrating the foot. Of the remaining 5 only 3 were visible on pre operative radiographs. Table 3 Operations performed Debridement and wash out
128
Debridement, wash out and removal foreign body
Debridement, wash out and tendon repair
Incision and drainage of abscess with debridement and wash out
16
1
1
125
Postoperative antibiotics were prescribed in 141 (97%) of the children. Five children were not prescribed antibiotics. There is no recorded reason for this and it must be assumed that this was a failure to adhere to the departmental policy; nevertheless these three patients did not develop either early or late infection. Cephradine was prescribed in 91% (133) of cases (see Table 4). There was one case of osteomyelitis. This was in an eleven year old boy who had stood on an old nail, which had penetrated his great toe through his training shoe. He had failed to present until 48 h later. Debridement was performed the following day and cefotaxime was administered intravenously for 48 h postoperatively. The patient was discharged on oral Cephradine, which was changed to oral Augmentin in accordance with the results of the swab cultures with sensitivities. Subsequent X-ray follow up showed the infection to resolve but the epiphyseal growth plate of the great toe became obliterated. The only other record of infection in this group of patients was in a ten year old boy who had stood on a rusty nail, which had also penetrated his great toe through the sole of his trainer. Debridement was performed within 24 h of the puncture wound and postoperative oral antibiotics were prescribed. The boy required further debridement and washout of the interphalangeal joint of his great toe six days later, when infection at this joint became clinically evident. Both the cases of infection were due to staphylococcus organisms sensitive to commonly used antibiotics. Pseudomonas aeruginosa was not seen in the cultures of either of the infected cases. The latter case settled quickly after a second washout and antibiotic treatment with Ciprofloxacin which was prescribed empirically before the culture and sensitivity results were known. Of the original 146 patients, 120 attended for follow in the outpatients department and were discharged after the wound had healed with no evidence of infection. None of the remaining 26 children who failed to attend for follow up re-presented with subsequent infection, either to the Orthopaedic Department or the Accident Department. Overall the infection rate in the entire group of patients in this study was 1.4%. If the late presenting case is excluded the infection is only 0.7%.
4. Discussion Puncture wounds through the sole of the foot are very common injuries, especially in children. Houston et al.
Table 4 Prophylactic antibiotic used Cephradine
Ciprofloxacin
Cefaclor
Cefotaxime
Cefuroxime metronidazole
Erythromycin
Amoxycillin
133
2
2
1
1
1
1
126
K.R. Sharpe et al. / Foot and Ankle Surgery 9 (2003) 123–127
reported in a series of children, 2303 foot punctures not infected at presentation, but patients seeking medical attention only represent the tip of an iceberg [1,12]. A questionnaire survey of the general population by Weber E.J. has shown that for every patient who presents with a foot puncture wound there may be at least the same numbers who do not [1]. The reported infection rate following puncture wounds is variable [1,5,14,15]. Of the two hundred respondents to Weber’s survey there was an overall infection rate of 6.4% [1]. Of those who had initially sought medical attention the infection rate was 11.4%, but of those who had never sought medical attention the infection rate was only 1.3%. There would therefore seem to be a degree of self-selection for those injuries at higher risk of infection [1]. Foot puncture wounds are common in our institution and represent a significant workload. The injury, like all childhood injuries, is most common in the summer months [19], [20]. Our series reveals, like others, that the injury is more common in boys than girls [19]. The most commonly reported scenario is a puncture by an unseen rusty nail, supporting the notion that boys are more likely to frequent derelict and prohibited areas where discarded nails and planks are likely to be found. The threat of inoculation with pathological organisms is increased if a dirty implement punctures the skin or if an implement passes through a heavily contaminated area immediately before puncturing the skin. Warm, moist conditions within footwear leads to colonisation of the insoles with a wide range of organisms, including pseudomonas aeruginosa [4]. There is some evidence to support the view that wearing training shoes (sneakers) increases the risk of puncture injuries and infection of the foot [2 – 4]. Training shoe wear is widespread in, and indeed, almost part of the uniform of our juvenile population. It is perhaps the ease with which a nail can pass through the rubber sole of such shoes that makes the wearer particularly vulnerable to puncture injury, especially if the footwear is used in inappropriate environments. Although the most common infecting organism following foot puncture wounds is Staphylococcus Aureus, infection with Pseudomonas aeruginosa is well recognized, especially in association with nail puncture through a training shoe, and can be destructive and difficult to treat [13,17,18]. The nature of this infective organism is one which can result in much tissue destruction and in rare cases result in persistent infection and deformity [8,16,11,17]. If infection of soft tissues progresses to, or is associated with, osteomyelitis or septic arthritis significant destruction and morbidity can follow [5 – 9,17]. Indeed Lang and Paterson have reported a case of below knee amputation, which was eventually necessary following a foot puncture wound [10]. Less severe complications are, of course, more common and include joint ankylosis, and deformities [9,11].
Our current management protocol for foot puncture wounds makes significant demands on our resources. Each child who undergoes wound debridement under general anaesthetic, consumes not only anaesthetic drugs and valuable operative time, but also occupies a hospital bed, commonly for at least 24 h. This management protocol is expensive. Some way of reducing this burden would be of benefit.
5. Conclusion Our results, confirm that the prophylactic surgical debridement of puncture wounds to the foot is a protocol that maintains a low infection rate. There are considerable time and resources to be spent carrying out this protocol however. The literature would support the use of prophylactic surgical debridement. There is some evidence to suggest that there are puncture wounds that may not require such aggressive management. If this group could be identified in some way, then they could avoid the need for admission and surgical treatment. We propose to conduct a randomised comparison between conservative and surgical treatment of foot puncture wounds to the foot, first excluding those with signs or symptoms of deep penetration or suspicion of having bone or joint involvement. This would hope to optimise the resources available but not adversely affect the outcome of treating this particular patient population.
References [1] Jacobs RF, Mc Carthy RE, Elser JM. Pseudomonas osteochondritis complicating puncture wounds of the foot in children: A ten year evaluation. The Journal of Infectious Diseases 1989;160(4):657 –61. [2] Brand RA, Black H. Pseudomonas osteomyelitis following puncture wounds of the foot in children. JBJS 1974;56A(8):1637–42. [3] Fisher MC, Goldsmith JF, Gilligan PH. Sneakers as a source of pseudomonas aeruginosa in children with osteomyelitis following puncture wounds. Journal of Paediatrics 1985;106(4):607– 9. [4] Weber EJ. Plantar puncture wounds: A survey to determine the incidence of infection. Journal of Accident and Emergency Medicine 1996;13:274–7. [5] Houston NA, Roy WA, Faust RA, Edwin DM. Tetanus prophylaxis in the treatment of puncture wounds in patients in the Deep South. Journal of Trauma 1962;2:439– 50. [6] Schwab RA, Powers RD. Conservative therapy of plantar puncture wounds. Journal of Emergency Medicine 1995;13(3):291–5. [7] Fitzgerald RH, Cowan JDE. Puncture wounds of the foot. Orthopaedic Clinics of North America 1975;6(4):965– 72. [8] Masterson E, Borton D, O’Brien TD. Victims of our climate. Injury 1993;24(4):247– 8. [9] Scheidt PC, Harel Y, Trumble AC, Jones DH, Overpeck MD, Bijur PE. The epidemiology of nonfatal injuries among US children and youth. American Journal of Public Health 1995;85(7): 932 –8. [10] Raz P, Miron D. Oral Ciprofloxacin for the treatment of infection following nail puncture wounds. Clinical Infectious Diseases 1995; 21:194–5.
K.R. Sharpe et al. / Foot and Ankle Surgery 9 (2003) 123–127 [11] Pennycook A, Makower R, O’Donnell AM. Puncture wounds of the foot: Can infective complications be avoided? Journal of The Royal Society of Medicine 1994;87:581–3. [12] Miller EH, Semian DW. Gram negative osteomyelitis following puncture wounds to the foot. JBJS 1975;57A(4):535–7. [13] Jacobs RF, Adelman L, Sack CM. Management of pseudomonas osteochondritis complicating puncture wounds of the foot. Paediatrics 1982;69(4):432–5. [14] Chusid MJ, Jacobs WM, Sty WR. Pseudomonas arthritis following puncture wounds of the foot. Journal of Paediatrics 1979;94(3):429–31. [15] Johanson PH. Pseudomonas infections of the foot following puncture
[16] [17] [18]
[19]
127
wounds. Journal of The American Medical Association 1968;204(3): 170–2. Riegler HF, Rouston GW. Complications of deep puncture wounds of the foot. Journal of Trauma 1979;19(1):18–22. Green NE, Bruno J. Pseudomonas infections of the foot after puncture wounds. Southern Medical Journal 1980;73(2):146– 9. Jarvis JG, Skipper J. Pseudomonas osteochondritis complicating puncture wounds in children. Journal Paediatric Orthopaedics 1994; 14(6):755– 9. Lang AG, Peterson HA. Osteomyelitis following puncture wounds of the foot in children. Journal of Trauma 1976;16(12):993–9.
Prophylactic surgical debridement of foot punctures in 146 children. A year’s practice with a review of the literature K.R. Sharpe*, G. Lamb, A. Bass, C.E. Bruce Department of Trauma and Orthopaedics, Royal Liverpool Children’s NHS Trust, Eaton Road, Liverpool, UK
Abstract We looked at a year’s experience of treating foot puncture injuries in a child population. There were 196 possible children identified from the theatre records. Of these, 146 had a history of a foot puncture injury. There were 111 boys and 35 girls ranging from two to fifteen years and a mean age of nine. There were two peaks at ten and thirteen. These injuries most frequently in the summer and were mostly as a result of a nail puncturing a training shoe. The majority were seen within 24 h of their injury and had their debridement within 24 h of their referral. Eleven per cent of children had a foreign body in the wound. Very few cases were discharged without prophylactic antibiotics but the most frequently used preparation had no anti pseudomonal properties. There was a 1.7% infection rate. There were no pseudomonas infections—only staphylococcus. q 2003 Elsevier Science Ltd. All rights reserved. Keywords: Foot punctures; Antibiotics; Pseudomonas
1. Introduction At the Royal Liverpool Children’s NHS Trust Hospital (Alder Hey Hospital) significant numbers of children are referred to the orthopaedic department with puncture wounds to the foot, most often through the sole of a training type shoe. It is well recognised that foot puncture wounds are susceptible to infection and may be especially vulnerable to infection with pseudomonas aeruginosa, which is a common inhabitant of footwear insoles. The potential for pseudomonas is of concern because the organism can cause significant destructive infection that can be difficult to eradicate [3,6]. Infection with pseudomonas has been especially associated with puncture injuries through the sole of training type shoes at the time of injury [4]. In light of the infection risk it is our current and longstanding practice to formally debride and wash out all puncture wounds under a general anaesthetic and the wound left open to heal by secondary intention. A course of oral antibiotics is prescribed and patients are routinely reviewed * Corresponding author. Address: 29, Boundary Road, West Kirby, Wirral, CH48 1LE UK. Tel.: þ 44-151-625-4061/07770-785-871. E-mail address: [email protected] (K.R. Sharpe).
at least once in the outpatient department after one to two weeks. Because this practice expends considerable time and resources, we were anxious to determine its necessity. The purpose of this study was to determine whether this policy has resulted in a lower infection rate in comparison with other reported studies. Our further aim was to determine whether we could identify particular subgroups of patients who might be especially vulnerable to infection, in terms of the site and nature of the puncture wound and would therefore benefit from this more aggressive policy.
2. Methods This is a retrospective study reviewing the theatre records over a twelve-month period between1st October 1997 and 30th September 1998. All patients who had undergone debridement of a foot puncture wound were included and the medical notes reviewed to collect the site and circumstances of the wound, the interval from injury to operation, the details of the operative record and the follow notes specifically to determine the rate of both early and late infection. Patients were excluded from the study if the injury was recorded to be anything other than a true puncture wound.
1268-7731/03/$ - see front matter q 2003 Elsevier Science Ltd. All rights reserved. doi:10.1016/S1268-7731(03)00042-0
124
K.R. Sharpe et al. / Foot and Ankle Surgery 9 (2003) 123–127
Chart 1.
3. Results One hundred and sixty children were identified from the theatre records of which only 146 had sustained a true puncture wound. The remaining 14 patients had nonpuncturing wounds. None of the patients had diabetes
mellitus or any other medical condition predisposing to infection The demographic details of the included patients are illustrated in Charts 1 and 2. Seventy six percent of patients were boys. The mean age was 9 years and most patients presented during the summer peaking in July. On average in
Chart 2.
K.R. Sharpe et al. / Foot and Ankle Surgery 9 (2003) 123–127 Table 1 Foot wear and item causing puncture wound
Trainers Shoes/Boots Slippers Socks Bare foot
Nail
Glass
Pin/Needle
Other
116 5 2 0 0
6 1 0 1 5
0 0 0 1 6
2 0 0 0 1
Table 2 Time distribution of treatment events of puncture wounds No. presenting ,1 Presentation to Referral to surgery Injury to day post injury referral (days) range (days) surgery (days) {mean} {mean} {mean} 138
0-14 {0.45}
0-3 {0.00}
0-14 {1.05}
the busiest month there was a foot puncture taken to theatre at least once a day. The puncture wounds involved penetration of a training shoe in the majority of cases (86%), with injuries to bare feet next most common (, 1%). The object causing the puncture was a nail in 84% of cases. The remaining cases were as a result of having stood on a number of other items as shown in Table 1. Ninety five percent of children were seen and referred within 24 h of their injury. Ninety seven percent of patients underwent surgical debridement within 24 h of their referral. There were a minority of late presenting cases, eight (5%) in number (Tables 2 and 3). Only simple debridement and washout was required in the majority of cases but 16 children (11%) also required the removal of foreign material. Eleven of these foreign bodies were clinically visible penetrating the foot. Of the remaining 5 only 3 were visible on pre operative radiographs. Table 3 Operations performed Debridement and wash out
128
Debridement, wash out and removal foreign body
Debridement, wash out and tendon repair
Incision and drainage of abscess with debridement and wash out
16
1
1
125
Postoperative antibiotics were prescribed in 141 (97%) of the children. Five children were not prescribed antibiotics. There is no recorded reason for this and it must be assumed that this was a failure to adhere to the departmental policy; nevertheless these three patients did not develop either early or late infection. Cephradine was prescribed in 91% (133) of cases (see Table 4). There was one case of osteomyelitis. This was in an eleven year old boy who had stood on an old nail, which had penetrated his great toe through his training shoe. He had failed to present until 48 h later. Debridement was performed the following day and cefotaxime was administered intravenously for 48 h postoperatively. The patient was discharged on oral Cephradine, which was changed to oral Augmentin in accordance with the results of the swab cultures with sensitivities. Subsequent X-ray follow up showed the infection to resolve but the epiphyseal growth plate of the great toe became obliterated. The only other record of infection in this group of patients was in a ten year old boy who had stood on a rusty nail, which had also penetrated his great toe through the sole of his trainer. Debridement was performed within 24 h of the puncture wound and postoperative oral antibiotics were prescribed. The boy required further debridement and washout of the interphalangeal joint of his great toe six days later, when infection at this joint became clinically evident. Both the cases of infection were due to staphylococcus organisms sensitive to commonly used antibiotics. Pseudomonas aeruginosa was not seen in the cultures of either of the infected cases. The latter case settled quickly after a second washout and antibiotic treatment with Ciprofloxacin which was prescribed empirically before the culture and sensitivity results were known. Of the original 146 patients, 120 attended for follow in the outpatients department and were discharged after the wound had healed with no evidence of infection. None of the remaining 26 children who failed to attend for follow up re-presented with subsequent infection, either to the Orthopaedic Department or the Accident Department. Overall the infection rate in the entire group of patients in this study was 1.4%. If the late presenting case is excluded the infection is only 0.7%.
4. Discussion Puncture wounds through the sole of the foot are very common injuries, especially in children. Houston et al.
Table 4 Prophylactic antibiotic used Cephradine
Ciprofloxacin
Cefaclor
Cefotaxime
Cefuroxime metronidazole
Erythromycin
Amoxycillin
133
2
2
1
1
1
1
126
K.R. Sharpe et al. / Foot and Ankle Surgery 9 (2003) 123–127
reported in a series of children, 2303 foot punctures not infected at presentation, but patients seeking medical attention only represent the tip of an iceberg [1,12]. A questionnaire survey of the general population by Weber E.J. has shown that for every patient who presents with a foot puncture wound there may be at least the same numbers who do not [1]. The reported infection rate following puncture wounds is variable [1,5,14,15]. Of the two hundred respondents to Weber’s survey there was an overall infection rate of 6.4% [1]. Of those who had initially sought medical attention the infection rate was 11.4%, but of those who had never sought medical attention the infection rate was only 1.3%. There would therefore seem to be a degree of self-selection for those injuries at higher risk of infection [1]. Foot puncture wounds are common in our institution and represent a significant workload. The injury, like all childhood injuries, is most common in the summer months [19], [20]. Our series reveals, like others, that the injury is more common in boys than girls [19]. The most commonly reported scenario is a puncture by an unseen rusty nail, supporting the notion that boys are more likely to frequent derelict and prohibited areas where discarded nails and planks are likely to be found. The threat of inoculation with pathological organisms is increased if a dirty implement punctures the skin or if an implement passes through a heavily contaminated area immediately before puncturing the skin. Warm, moist conditions within footwear leads to colonisation of the insoles with a wide range of organisms, including pseudomonas aeruginosa [4]. There is some evidence to support the view that wearing training shoes (sneakers) increases the risk of puncture injuries and infection of the foot [2 – 4]. Training shoe wear is widespread in, and indeed, almost part of the uniform of our juvenile population. It is perhaps the ease with which a nail can pass through the rubber sole of such shoes that makes the wearer particularly vulnerable to puncture injury, especially if the footwear is used in inappropriate environments. Although the most common infecting organism following foot puncture wounds is Staphylococcus Aureus, infection with Pseudomonas aeruginosa is well recognized, especially in association with nail puncture through a training shoe, and can be destructive and difficult to treat [13,17,18]. The nature of this infective organism is one which can result in much tissue destruction and in rare cases result in persistent infection and deformity [8,16,11,17]. If infection of soft tissues progresses to, or is associated with, osteomyelitis or septic arthritis significant destruction and morbidity can follow [5 – 9,17]. Indeed Lang and Paterson have reported a case of below knee amputation, which was eventually necessary following a foot puncture wound [10]. Less severe complications are, of course, more common and include joint ankylosis, and deformities [9,11].
Our current management protocol for foot puncture wounds makes significant demands on our resources. Each child who undergoes wound debridement under general anaesthetic, consumes not only anaesthetic drugs and valuable operative time, but also occupies a hospital bed, commonly for at least 24 h. This management protocol is expensive. Some way of reducing this burden would be of benefit.
5. Conclusion Our results, confirm that the prophylactic surgical debridement of puncture wounds to the foot is a protocol that maintains a low infection rate. There are considerable time and resources to be spent carrying out this protocol however. The literature would support the use of prophylactic surgical debridement. There is some evidence to suggest that there are puncture wounds that may not require such aggressive management. If this group could be identified in some way, then they could avoid the need for admission and surgical treatment. We propose to conduct a randomised comparison between conservative and surgical treatment of foot puncture wounds to the foot, first excluding those with signs or symptoms of deep penetration or suspicion of having bone or joint involvement. This would hope to optimise the resources available but not adversely affect the outcome of treating this particular patient population.
References [1] Jacobs RF, Mc Carthy RE, Elser JM. Pseudomonas osteochondritis complicating puncture wounds of the foot in children: A ten year evaluation. The Journal of Infectious Diseases 1989;160(4):657 –61. [2] Brand RA, Black H. Pseudomonas osteomyelitis following puncture wounds of the foot in children. JBJS 1974;56A(8):1637–42. [3] Fisher MC, Goldsmith JF, Gilligan PH. Sneakers as a source of pseudomonas aeruginosa in children with osteomyelitis following puncture wounds. Journal of Paediatrics 1985;106(4):607– 9. [4] Weber EJ. Plantar puncture wounds: A survey to determine the incidence of infection. Journal of Accident and Emergency Medicine 1996;13:274–7. [5] Houston NA, Roy WA, Faust RA, Edwin DM. Tetanus prophylaxis in the treatment of puncture wounds in patients in the Deep South. Journal of Trauma 1962;2:439– 50. [6] Schwab RA, Powers RD. Conservative therapy of plantar puncture wounds. Journal of Emergency Medicine 1995;13(3):291–5. [7] Fitzgerald RH, Cowan JDE. Puncture wounds of the foot. Orthopaedic Clinics of North America 1975;6(4):965– 72. [8] Masterson E, Borton D, O’Brien TD. Victims of our climate. Injury 1993;24(4):247– 8. [9] Scheidt PC, Harel Y, Trumble AC, Jones DH, Overpeck MD, Bijur PE. The epidemiology of nonfatal injuries among US children and youth. American Journal of Public Health 1995;85(7): 932 –8. [10] Raz P, Miron D. Oral Ciprofloxacin for the treatment of infection following nail puncture wounds. Clinical Infectious Diseases 1995; 21:194–5.
K.R. Sharpe et al. / Foot and Ankle Surgery 9 (2003) 123–127 [11] Pennycook A, Makower R, O’Donnell AM. Puncture wounds of the foot: Can infective complications be avoided? Journal of The Royal Society of Medicine 1994;87:581–3. [12] Miller EH, Semian DW. Gram negative osteomyelitis following puncture wounds to the foot. JBJS 1975;57A(4):535–7. [13] Jacobs RF, Adelman L, Sack CM. Management of pseudomonas osteochondritis complicating puncture wounds of the foot. Paediatrics 1982;69(4):432–5. [14] Chusid MJ, Jacobs WM, Sty WR. Pseudomonas arthritis following puncture wounds of the foot. Journal of Paediatrics 1979;94(3):429–31. [15] Johanson PH. Pseudomonas infections of the foot following puncture
[16] [17] [18]
[19]
127
wounds. Journal of The American Medical Association 1968;204(3): 170–2. Riegler HF, Rouston GW. Complications of deep puncture wounds of the foot. Journal of Trauma 1979;19(1):18–22. Green NE, Bruno J. Pseudomonas infections of the foot after puncture wounds. Southern Medical Journal 1980;73(2):146– 9. Jarvis JG, Skipper J. Pseudomonas osteochondritis complicating puncture wounds in children. Journal Paediatric Orthopaedics 1994; 14(6):755– 9. Lang AG, Peterson HA. Osteomyelitis following puncture wounds of the foot in children. Journal of Trauma 1976;16(12):993–9.