Randomized Control Trial Conservative Management vs

Cruciate incision of Puncture Wounds In the Plantar area

Oliver S Leyson, MD

Edgardo Penserga MD, FPCS, FPSGS

Reynaldo O. Joson MD, FPCS

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Reprint requests: Oliver S. Leyson MD, Department of Surgery, Ospital Ng Maynila Medical Centre, Quirino Avenue,Malate, Manila, Philippines.

bstract

Background: Plantar puncture wound is the most common emergency case in the emergency room afflicting all ages.  Residents would often use incision and debridement of the wound while others would prefer a conservative management that relies on pain-relievers and anti-tetanus prophylaxis.  Moreover, devastating sequela such as cellulitis, abscesses on the puncture site and even osteomyelitis has been noted.  In the light of providing high quality care at the lowest possible cost, the values of such practice need to be assessed. Objective: To determine the effectiveness of non-intervention with comparison of the cruciate incision and debridement in the management of punctured wounds of the plantar area; and to create a standard management of punctured wounds of the plantar area in Hospital X. Methods: All patients regardless of age, who sought consult from January-August 2006 in OMMC with acute punctured wounds of the plantar area.  Group A with no intervention and Group B with cruciate incision and debridement of punctured wounds on the plantar area.  Results were analyzed. All patients were followed up one week. The presence of pus and erythema were used as a parameter for wound infection. Result: Overall infection rate was about 14%. Group A had 4(11%) while Group B 7 (16%). Using Chi-square both parameters were statistically insignificant (p=0.3). Conclusion:  Conservative Management of plantar puncture wounds can be done in the emergency room as a standard management in Hospital X.

Key words: puncture wound, plantar area

Introduction

            In the Department of Surgery at Hospital X, plantar puncture wounds have always been a part of daily our cases.  Statistics showed emergency consult in the year 2005 alone, plantar puncture wounds reached up to 300 cases.  Since 2001, the main author noticed no standard treatment for this kind of trauma cases. Surgical residents would often use incision and debridement of the wound while others would prefer a conservative management. Conservative management usually relies on pain-relievers and anti-tetanus prophylaxis. Moreover, devastating sequela such as cellulitis, abscesses on the punctured site and even osteomyelitis has been noted (4).

In September 2005, realizing the presence of variations and their impact on quality patient care and resource utilization, the Hospital X Department of Surgery decided to initiate action researches to standardize the management of plantar puncture wounds.

In the light of quality health care improvement and cost-consciousness there is a need to review the practices and surgical approaches, especially if there is variations or lack of standardization.  The concept and methodology of an action research was utilized (1,2), namely: analysis of the problems, research designs on how to solve the problems, implementation of action plan, and then evaluation of results of implementation.  After the analysis of problems which revealed variations in practices and approaches with no guidelines and which affected resource utilization, the following questions and premises were formulated by the staff of surgery which served as the take-off points for the research designs on how to solve the problems.

The presence of this information will facilitate decision-making on the type and approach of plantar puncture wounds.  In the Philippines, however, there are no published data on this topic.  

The specific objectives of the project, thus, consisted of the following:  to determine the effectiveness of non-intervention with comparison of the cruciate incision and debridement in the management of punctured wounds of the plantar area; and to create a standard management of punctured wounds of the plantar area in Hospital X.

This paper will limit its report on the management of plantar puncture wounds.

Methodology:

All patients regardless of age, who sought consult from January-August 2006 in OMMC either on Surgery ER or referral from other Departments with acute punctured wounds of the plantar area.  All patients diagnosed to have plantar puncture wounds were included in the study.  Randomization was done using a table of random numbers.  All sets ending in even numbers were assigned to the Group A and all odd numbers to the Group B. Group A with no intervention and Group B with cruciate incision and debridement of punctured wounds on the plantar area.  Using a number 10 blade, remove the cornified epithelium and any debris that has collected beneath its surface.  Furthermore, the serrated epidermal skin edges overlying the puncture track may be painlessly trimmed.

            Informed consent was obtained from all patients. All patients were given tetanus toxoid 0.5 ml intramuscularly and anti-tetanus serum 4,500 U intramuscularly after a negative skin test. Tetanus prophylaxis depends on the severity and type of the punctured wound as well as history of immunization.  All patients were treated as out-patient-basis.  All patients were given home medications such as Paracetamol 500 mg tablet every four hours for pain.  All patients were asked to follow up two days after on the out-patient-department and after two weeks.

Results:

A total of 81 subject populations were accrued, with the age ranged from 3 to 63-years-old with a mean of 26.  There were 39 males and 42 females.  A total of 36 patients belong to the Group A, with 16 males and 20 females whereas in the Group B there were 45 patients with 22 males and 23 females.

Overall infection rate for plantar puncture wounds was 11% (7).  There is no significant difference between the Group A, 4 (16%) and Group B, 7 (84%) in terms of infection rate among the population (Appendix 1).

Complications such as infection, cellulitis, and abscesses, were noted with a mean follow-up of 14 days. 14% showed signs of infection characterized with erythema, pain and swelling that requires further management such as antibiotic treatment.  Among patients with signs of infection, only one required admission, incision and drainage.             

 Discussion:

            Small, clean, superficial puncture wounds uniformly do well.  The pathophysiology and management of a wound is dependent upon the material that punctured the foot, the location, and depth, time to presentation, footwear and underlying health status of the victim. Punctures in the metatarsal-phalangeal joint area may be of higher risk of bone and joint involvement. Children brought by a parent, adults with on-the-job injury and patients seeking tetanus shots tend to present earlier and thus have a lower incidence of infection (4).  Patients who present after 24 hours may have an early subclinical infection. Unsuspected fragments of sock or rubber sole are a major source of potential infection. When the foot is punctured, the cornified epithelium acts as a spatula, cleaning off any loose material from the penetrating object as it slides by. This debris often collects just beneath this cornified layer which then acts like a trap door holding it in (4).

            Left in place, this debris may lead to infection, cellulitis or abscess. Saucerization or cruciate incision of wound edges allows for the removal of debris and the unroofing of superficial small foreign bodies or abscesses found beneath the thickly cornified skin surfaces (5).  Osteomyelitis caused by Pseudomonas aeruginosa remains the most devastating sequela. The incidence of osteomyelitis is estimated to be between 0.4% and 0.6%. Nails through tennis shoes into the metatarsal heads are high risk injuries and should be referred for orthopedic follow up (6).

However, the results of the study did prove that conservative management has a role in acute setting. Considering the type of penetrating objects its sterility and how large, was the major limitation of the study.  Higher infection rate was seen in the incision and drainage compared to conservative management though not statistically significant maybe attributable to the sterility of the object used.

The value of this study in a tertiary city government hospital like Hospital X is that a management of plantar puncture wound will lead to a standardized management with rooms for individualization and this rationalized and standardized management will in turn prevent confusion among the surgical residents and nursing staff; minimize hospital and patient expenses; and serve as a guide in estimating hospital and patient budgeting for postoperative expenses.

            The authors plan to institutionalize the findings of this study by incorporating them into a standard policy and procedures of plantar puncture wound management of patients handled by the Departments of Surgery.  Constant monitoring, review, and validation of the policy and procedures will be done after this study as part of oversight and continual improvement in the ever changing setting in the hospital.

 References:

1.      Cohen L, Manion L. Research Methods in Education. London, Croom Helm, 1980; 31(2), 285-313.

2.      Marguiles N. Managing change in health care organization. Medical care, 1977; 15:693-704.

3.      White PF. The role of non-opioid analgesic techniques in the management of pain after ambulatory surgery. Anesth Analg 2002; 94:577-85.

4.      Patzakis MJ, Wilkins J, Brien WM, Carter VS: Wound site as a predictor of complications following deep nail punctures to the foot. West J Med         1989; 150:545-547.

5.       Fitzgerald RH, Cowan JDE: Puncture wounds of the foot. Ortho Clin N Am 1975; 6(4):965-972.

6.      Das De S: Pseudomonasosteomyelitis following puncture wounds of the foot in children. Injury. 1981;12(4):334-9.

7.       Chisholm CD, Schlesser JF: Plantar puncture wounds: controversies and Treatment recommendations. Ann Emerg Med 1989; 18:1352-1357.

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

9.      Verdile VP, Freed HA, Gerard J: Puncture wounds to the foot. J Emerg Med 1987; 7:193-199.

Table 1.  Age and Sex Distribution.

Table 2: Distribution of patients among Group A and Group B.

Appendix 1

Plantar puncture wounds infection rate.

Null hypothesis: no difference in the 2 forms of treatment

Chi square = 0.80532

Level of significance = 0.05

Probability (p) = 0.371

p > level of significance, therefore Null hypothesis is not rejected

There is no statistical difference between two forms of treatment using the chi square test.