To review, this case involved a 19 y/o male construction worker who presented to the ER at St. Mary Hospital, Hoboken, New Jersey, one hour after sustaining a puncture wound from a nail gun to the dorsum of his right foot. See Residency Insight 52 for the complete case presentation.

FOLLOW UP

This week we present the final clinical outcome and the Interactive Poll results.

Below are comparison radiographs showing pre and post nail removal. Note the defect evident in the base of the 3rd metatarsal from the nail puncture.

Discharge medications for this patient included an Rx for Ciprofloxacin 500mg PO BID. The patient was followed weekly for 3 weeks. Sutures were removed at the second week and no clinical signs of infection were noted. The patient denied any pain or disability and returned to full activity with no long term complications.

Although considered a contaminated wound, this particular situation was minimized by the fact that the nail was relatively clean since it was fired directly from a nail gun. In addition there was no significant delay in care since the surgical removal was performed the same day. The fact that the nail did not go through the sole of the shoe also reduced the chance of pseudomonal osteomyelitis.

 NOTE from Editor

On the question of antibiotics post-operatively, a large contingent of you would argue that a po fluoroquinolone would be the correct choice, because of the ability of that class to achieve good bone penetration. In fact, a full 50% of the 104 of you who responded to the survey chose Cipro as the antibiotic of choice in this case.  Others would argue that the best Staph and Strep drug should be the correct choice. However, I asked respected educator and author Warren Joseph, DPM to render an opinion and here is his response, which many of you will find surprising:

“This is a really interesting case, but I somewhat disagree with the Cipro pre-op and am afraid of the potential for everybody jumping on the Cipro as the correct answer.  Although we know that Pseudomonas aeruginosa is the most common pathogen of post puncture wound osteomyelitis it is NOT the most common pathogen in post puncture wound infections, Staph and Strep are.  We also know that Cipro is an absolutely lousy anti-Staph drug. Furthermore, there is no medical evidence that antibiotic prophylaxis following puncture wounds has any bearing on the outcome of the cases or the risk of infection.  This was shown in some nice work done years ago by Fitzgerald and Cowen and more recently, in the foot by Corey.  The use of Cipro, if anything, will predispose the patient to a resistant gram positive infection post-op and not necessarily be protective against PA osteomyelitis.  Bottom line, once the surgical debridement and irrigation were performed, there is NO EVIDENCE that ANY antibiotic was indicated.” -  Warren Joseph, DPM