For many wound care experts, puncture wounds are one of the most interesting injuries to treat. They often have little to no sign of hemorrhaging and present with a benign appearance, causing many patients and providers to overlook them. However, these wounds can be much more complex than they appear.
Delayed referrals, a missed diagnosis, and inappropriate treatment are all recipes for complications that extend beyond just a puncture wound. Therefore, even the most skilled clinicians could do with a refresher on what to do when presented with this type of injury.
So, if you want to gain more insight into puncture wounds or just need a quick review, keep reading!
What Is a Puncture Wound?
There are four main types of open wounds, and puncture wounds are one of them. Unlike an abrasion wound, where a rough object has rubbed off the skin, a puncture wound is intentionally or unintentionally caused by a sharp instrument breaking the skin.
They typically occur when the force of a pointed item causes the object to penetrate the skin. In some cases, it even pierces deep tissues.
How Do Puncture Wounds Differ from Other Open Wounds?
What makes puncture wounds much different than other wound types is their depth. In fact, their depth is so distinctive that they’re defined as a wound whose depth is greater than its width. From an appearance perspective, a puncture wound might just look like a narrow, unalarming, small hole in the skin. However, don’t let these wounds fool you, as there could be a lot you can’t see off the bat.
While cuts might look more severe due to the long tears they produce and the occasional excessive bleeding, they’re typically easier to treat. When dealing with puncture wounds, though, it’s often challenging to see exactly how much damage has been caused or if a foreign body is lodged in the skin.
What Causes Puncture Wounds?
Let’s say you’re gardening in your backyard, and suddenly, you feel an object push through the skin on the bottom of your right foot. You glance at your foot and the ground, realizing you’ve stepped on a nail.
Stepping or Falling on an Object
Stories like the one above aren’t uncommon among adults or children. This is why it’s not a surprise that stepping on a sharp object is one of the most common causes of puncture wounds. Interestingly, plantar puncture wounds make up the majority of these types of injuries.
Puncture wounds may also occur from falling on a pointy item.
Some of those sharp objects may include:
- Tacks
- Nails
- Needles
- Glass
- Ice picks
- Knives
Nails, specifically, are the most frequently seen objects in puncture wounds.
Intentional Punctures
Some puncture wounds are done on purpose, such as in healthcare settings. Needle punctures may be done to draw blood or set up intravenous (IV) lines. At home, this may occur when administering treatment like fertility or autoimmune medications. These may not be common wounds that are seen by clinicians often, but they can develop complications, so they’re worth keeping in mind.
Animal and Human Bites
Puncture wounds may also come from getting bitten by an animal or human. However, keep in mind that not all bites are puncture wounds. Some are tears, bruises, or something else. This will depend on whether or not the bite breaks the skin and what shape and depth the wound takes.
What Symptoms Do Puncture Wounds Cause?
Patients who’ve suffered a puncture wound may experience the following symptoms:
- Mild bleeding
- Functional limitations at or near the wound site
- Numbness
- Tingling
- Pain
Outwardly, these wounds may not appear to bleed much, but deeper wounds may cause internal bleeding.
How to Determine the Severity of a Puncture Wound
If a patient presents with a puncture wound, there are several key factors wound care providers can evaluate to determine its severity.
Depth of the Puncture Wound
One way to determine these wounds’ severity is to assess their depth. The deeper it is, the more likely one will face complications. Mount Sinai advises that individuals with wounds more than a quarter inch deep seek medical care. Wounds of that depth can cause arterial injury, leading to poor blood flow and impaired healing. You’ll also want to assess if the wound has come into contact with bone.
One of the easier ways to classify the severity of general wounds is to consider the following:
- Superficial wounds. These only involve the epidermis, the outermost layer of skin.
- Partial thickness wounds. The injury reaches the dermis, the next deepest layer of skin.
- Full-thickness wounds. These wounds go through the skin, reaching bone, organs, and/or subcutaneous fat. This type of wound requires emergency care, and depending on your care setting, may be one of the most common types that you see.
Keep in mind that puncture wounds have a higher risk of infection than other traumatic lacerations. This is because it’s difficult to see and clean to the full depth of injury, and why small punctures like those at injection sites should not be ignored if presenting with signs of infection.
Location of the Puncture Wound
Although puncture wounds in the foot are the most common, these injuries can happen anywhere on the body. Punctures in the head, abdomen, neck, or chest are seen as more severe due to the vital structures near them.
However, other areas, like the legs and arms, can still be considered serious puncture wounds. For instance, is the wound just near a major artery, or did it actually strike an artery? If bleeding has occurred for more than 15 minutes and doesn’t seem to be slowing down, that’s a sign of an arterial puncture. You’ll want to assess if any other anatomy is involved as well, like nerves, fascia, muscles, and tendons.
Wound care experts should also ask themselves if the location of the wound is one where it’ll be challenging to keep clean. As you know, a dirty wound can significantly increase a patient’s risk of infection.
In addition, is the wound placed in a region that’s difficult to offload pressure? This matters because prolonged pressure can lead to tissue ischemia and necrosis, thus worsening the wound.
Foreign Bodies in the Wound
Anytime a wound involves penetration of an object, it’s considered a dirty wound. This is because a foreign object, whether it’s a toothpick, sewing needle, or something else, isn’t sterile. If it’s a foot puncture wound and the patient was wearing socks or shoes, the patient even risks having particles from those items trapped in the wound.
If objects remain embedded at the site, it increases the risk of immediate and potential future complications. Yet, removing a penetrating object also creates a favorable environment for infection. In some situations, leaving the foreign body in place might be less risky. However, this is primarily determined by the composition of the foreign body.
The composition of foreign bodies can be grouped into three categories: metallic, organic, and inorganic.
- Metallic objects: These may include objects made of materials like steel, copper, or brass. Because they have a high atomic number, it’s easier to identify them in the body using plain radiographs. Those with the potential for toxicity (e.g., heavy metals) or allergic reactions should be removed as soon as possible.
- Organic objects: They have vegetative origins and include materials like wood splinters and plant thorns. Organic objects are difficult to find using radiographs, so an ultrasound or magnetic resonance imaging (MRI) may be a better solution. Clinicians must be cautious when exploring a wound with these objects. In some cases, removal is too risky, and leaving the organic object in place is better.
- Inorganic objects: Non-living objects like glass, plastic, or rubber may be visible using ultrasounds or radiographs, but this varies. For instance, plain radiographs are better for glass.
However, if the wound is highly contaminated, such as those that involve teeth or soil, foreign body removal, and extensive irrigation are necessary. If the patient can feel the object and is experiencing uninterrupted pain, this is also a cause for object removal. The foreign body should also be withdrawn if it’s near a fractured bone or affecting tendons, joints, vascular structures, or nerves.
The best time for foreign body removal is the first 24 hours after an injury. This permits better assessment of the entry and exit sites of the wound and lowers the inflammatory response and scar formation.
Lastly, if the puncture wound is assumed to be very deep and likely impacting certain structures, performing a computed tomography (CT) scan is helpful. Otherwise, the object may be missed using other imaging tools.
Wounds Caused by an Animal Bite or Human Bite
Puncture wounds that come from animals and humans can lead to some very serious complications. Even seemingly minor wounds can become infected, so patients must be carefully evaluated.
Animal Bites
Domesticated dogs and cats cause nearly all of the bites seen in the emergency department. Dog bites usually involve more tearing and ripping and may not be considered puncture wounds. However, cat bites tend to be deep and narrow as they often bite and hold.
Interestingly, though, cat puncture wounds seal quickly, often causing patients to delay treatment as they believe everything is okay. Unfortunately, the sealed wound creates an oxygen-free environment for new bacteria.
Some of the most common organisms in animal bite wounds are: Pasteurella multocida, S. aureus, Bacteroides tectum, and Fusobacterium, Capnocytophaga, and Porphyromonas species. For this reason, animal bites with a puncture characteristic must be treated with amoxicillin-clavulanate.
Human Bites
Clenched fist injuries are considered one of the worst human bite wounds. These occur when human teeth come into contact with a closed fist. They often leave a small, harmless-appearing puncture that’s said to be easily missed during evaluation. However, the wound is often severe because of damage to the soft tissue, extensor tendon, and sheath. In some cases, even a metacarpophalangeal (MCP) joint is injured.
The MCP joint and extensor tendon are avascular structures with limited ability to fight infection. In addition, human saliva carries nearly a hundred million microbes per milliliter and almost 50 species of bacteria. Because of this, antibiotic management is often recommended for human bites.
Length of Time Since Injury
When assessing wounds, it’s critical to determine the length of time since injury. Has it been days or hours? If it’s been longer than three hours, it’s recommended that clinicians begin antibiotics.
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Potential Puncture Wound Complications
If a patient’s puncture wound goes untreated or they receive delayed, or even inadequate treatment, complications may occur. This is partially because puncture wounds lay out a direct pathway for bacteria to enter the body.
- Tetanus: All wounds, besides clean minor cuts, are tetanus-prone. Objects, like contaminated metal instruments and soil, may contain the Clostridium tetani bacteria.
- Rabies: Animals, like bats, skunks, and raccoons, may carry rabies in their saliva, which is then transferred to a human if they’re bitten. Keep in mind that some bat bites are so small that a patient may not notice they’ve been bitten. Generally, rabies vaccinations should be administered after an animal bite if the patient has not been vaccinated in the past.
- Sepsis: Blood poisoning can occur if an infection caused by the puncture wound spreads to the bloodstream. Assess your patient for symptoms like low blood pressure, fever, and chills.
- Nerve damage: Deeper wounds may damage nearby nerves, leading to tingling and numbness. Wounds to the small spaces within the hands and feet are especially prone to nerve damage.
- Osteomyelitis: If the site of a severe puncture wound becomes infected, which may happen two to five days after injury, the germs can spread into nearby bone. In some cases, it even advances to an adjacent joint, causing septic arthritis.
- Amputation: While rare, critical cases may lead to the loss of a limb.
Treatment of Puncture Wounds
Proper treatment of puncture injuries reduces the risk of complications and enhances patient outcomes. As a wound care clinician, your immediate goal is to prevent further issues, preserve function, and encourage wound closure.
After assessing the injury and the individual patient’s health, which is the trickiest part of the puncture wound treatment process, treatment methodologies may include:
- Trying to stop the bleeding
- Cleaning the wound/high-pressure irrigation
- Completing debridement if necessary
- Administering prophylactic antibiotics, especially for bite wounds
- Performing tetanus prophylaxis if it’s been ten years since the patient was last vaccinated
- Removing foreign bodies, if necessary and possible
- Applying a sterile dressing
- Suggesting or prescribing pain medication to help relieve pain and inflammation
Puncture Wounds: A Small Injury with a Potentially Big Impact
Although puncture wounds may present as a minor issue, they can be tricky to properly diagnose and may require aggressive treatment. Fortunately, timely and appropriate intervention can make a big difference for a patient.
As a wound care expert, we know your goal is to minimize risks and maximize wound healing. You want to ensure your patients walk away from your practice satisfied with their treatment and have a smooth recovery. These goals are undoubtedly possible by staying up-to-date on puncture wound best practices and working with other clinicians.
