1	Case Presentation September 2006 Bonnie Lin, DPM PGY-1 St.Vincent Charity Hospital
2	CC: Stepped on a pencil HPI: 31 y.o. white male with no PMH presents to ED six hours after stepping onto a pencil bare foot. Patient states he attempted to remove foreign body but was unsuccessful. PMH: tetanus immunization > 5 yrs Denies any Illness, Sx Hx, Hospital Stays, Meds, Allergies Admits to social EtOH usage, denies tobacco and illicit drug usage
3	Tetanus Prophylaxis No Hx of Immunization Tetanus immunoglobin 250 Units IM Tetanus Toxoid 0.5 mL Two additional Tetanus Toxoid 0.5 mL booster at monthly intervals Immunization greater than 5 years Tetanus Toxoid 0.5 mL Contaminated wounds in patients not immunized in two years Tetanus Toxoid 0.5 mL
4	Physical Exam O: General appearance- alert, awake, & oriented x 3 Vital signs- afebrile Derm- 0.5 x 0.5 cm open wound plantar medial instep of left foot, active bleeding, no purulence Vascular- intact; no erythema, no edema, no lymphadema, no lympadenopathy Neurologic- sensate Msk- no gross deformity, no loss of ROM Labs- normal value
5	Classification of Wound Contamination Clean less than 6 hours post trauma Contaminated greater than 6 hours post trauma; debris & necrotic tissue present; extensive soft tissue damage Dirty/Infected clinical signs of infection: increased pain, swelling, redness, or warmth around the affected area; red streaks extending from lymph nodes in the affected area toward the body; drainage of pus from the area; swollen lymph nodes in the neck, armpit, or groin; & fever
6	Patzaki Classification for Puncture Injury of the Foot Zone I: metatarsal necks and distal -most common and highest risk for complications such as osteomyelitis and/or pyarthrosis due to the small amount of overlying soft tissue and that metatarsal heads are a primary weight-bearing area of the foot. Zone II: metatarsal necks to mid-tarsal joints -least common because metatarsal arch and abundant soft tissue pad offer protection against bone or joint penetration. Zone III: calcaneus and talus
7	Modalities to Detect Foreign Body Radiograph Ultrasound Computed Tomography (CT) Magnetic Resonance Imaging (MRI)
8	Radiographic Images
9	Radiographic Image
10	Antibiotic Antibiotic Therapy should be administered to patients with infection following puncture wounds common microorganisms in puncture wounds: staphylococcus aureus group A beta-hemolytic streptococci bacteroides pseudomonas aeruginosa common antibiotics: penicillins first generation cephalosporins clindamycin (alt to pcn)
11	Treatment Patient was prepped in the ED procedure Tetanus Toxoid administered 1 gm of IV Ancef administered Local anesthesia administered Following sterile technique, a linear incision made, with use of a pair of forceps, the embedded piece of pencil removed. Wound was flush with copious lavage using normal sterile saline Skin closure with prolene suture
12	"The Foreign Body" The Foreign Body
13	S/P Foreign Body Removal Radiographic Images
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15	S/P Management Cephalexin (Keflex) 500 mg BID for 2 weeks WB as tolerated in post-Op shoe Follow-up with physician in one week or sooner if signs of infection
16	Follow Up F/U one week. No signs of infection. WB in post-op shoe. DSG I/C/D. F/U two week. No signs of infection. Sutures removed. No complications. Return to regular shoegear.
17	Reference Mizel, MS, Steinmetz, ND, Trepman, E. Detection of Wooden Foreign Bodies in Muscle Tissue: Experimental Comparsion of Computed Tomography, Magnetic Resonance Imaging, and Ultrasonography. Foot Ankle Int 1994; 15:8: 437- 443 Fornage, BD, Schernberg FL. Sonographic Diagnosis of Foreign Bodies of the Distal Extremities. Am J Roentgenology 147: 567- 569 Fishman, TD. How to Diagnose and Treat Foreign Body Injuries. Podiatry Today 2003: 16: 6: 65- 70 Reinherz, RP, Hong, DT, Tisa, LM, et. al. Management of puncture wounds of the foot. J Foot Surg 1985; 24: 288 Fitzerald, RH, Cowan, JD. Puncture wounds of the foot. Orthop Clin North Am 1975; 6:965 Watkins, LW. Pocket Podiatrics 3^rd Ed. 2001 Baddour, LM. Puncture wounds to the plantar surface of the foot. www.uptodate.com Peterson, JJ, Bancroft, LW, Kransdorf, MJ. Wooden Foreign Bodies. Am J Roentgenology 2002; 178: 557- 562 Hunter, TB, Taljanovic MS. Foreign Bodies. Radiographics 2003; 23: 737- 757 Patzakis, MJ, Wilkins, J, Brien WW, Carter, VS. Wound Site as a Predictor of Complications Following Deep Nail Punctures to the Foot. The Western Journal of Medicine 1989; 150:5 545- 547