Morning Report: 7/30/2015

Thanks to Dr. Muhlfelder for presenting today’s Morning Report!

Plantar Puncture Wounds

How remote is the injury? Comorbidities? Tetanus Status?

• Diabetics present later 2/2 neuropathy/decreased sensation, 3x risk of osteo

For all, consider deep penetration given weight-bearing area, risk for osteo ~ 0.5%

Imaging???

• Assess for retained FB: glass, wood

Analgesia: know your anatomy!

Tibial Nerve runs posterior to medial malleolus and tibial artery

“Tom, Dick, and Very Nervous Harry” (anterior to posterior)

T-Tibialis Posterior Tendon

D- Flexor Digitorum Tendon

A-Posterior Tibial Artery

V- Posterior Tibial Veins

N- Tibial Nerve

H- Flexor Hallucis Longus Tendon

Nerve Block

Lidocaine max dose : w/o 4.5 mg/kg: duration 30 min-1 hr, w/ epi 7mg/kg: 2-6 hrs

Bupivicaine: w/o 2.5 mg/kg: 2-4 hrs, w/epi max 225 mg: 3-7 hrs

Treatment

• Debridement + irrigation
• Tetanus
• Abx?? “.. no evidence-based recommendations can be made regarding the use of prophylactic abx for plantar puncture wounds, and physicians are counseled to ‘follow local advice’ in deciding when or if to treat.” – Tintanelli

<24 hrs: anticipatory, if DM consider covering gram +

24-72: worsened symptoms, cover gram +, consider covering pseudomonas if + shoes (Pseudomonas love rubber soles!!!!)

>72 hrs + infxn: COVER Pseudo!

• Analgesia
• FREQUENT RE-EVAL

Complications

• Cellulitis, Osteo
• Nerve block: nerve laceration, IV injection –> cardio/cns tox

References:

AU, Raz R, Miron D. Oral ciprofloxacin for treatment of infection following nail puncture wounds of the foot.

Clin Infect Dis. 1995;21(1):194.

Lammers RL, Magill T. Detection and management of foreign bodies in soft tissue. Emerg Med Clin North Amer. (1992); 10:767.

Redborg, KE. Ultrasound improves the success rate of tibial nerve block at the ankle. Reg Anesth Pain Med. 2009; 34(3) 256-260.

Schwab RA, Powers RD: Conservative therapy of plantar puncture wounds. J Emerg Med 1995;13:291-295

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Jay Khadpe MD

Editor in Chief of "The Original Kings of County" Assistant Professor of Emergency Medicine Assistant Residency Director SUNY Downstate / Kings County Hospital

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