Weird Case Wednesdays - How complicated could a nail puncture really be?

I strongly believe that the more my PI and MedMal attorney clients understand medicine themselves, the better all of our lives will be. Of course, some of you experienced attorneys out there already know so much medicine that you could come pull an ER shift with me today! Actually, could you? We’re pretty understaffed (kidding… kind of…).

On Wednesdays, I’m going to be dropping little clinical pearls of “Weird Cases” and their consequences. These will often be situations where there is a LOT more potential liability or future medicals than might be obvious at first…

Let's consider the case of a 42-year-old healthy, hard-working father of three, who was out for a morning run in his newly built neighborhood. It’s dark outside and he didn’t notice some construction trash strewn across the sidewalk. He steps heavily on a nail which was in the debris. The nail penetrates his footwear and is deeply lodged in the plantar surface (the sole) of his foot. He presents to an ER or urgent care limping and supported by his running buddy with the nail still lodged in his foot. What is to be done??

Well that’s easy, right? Just pull the stupid nail out, maybe put him on antibiotics, and send him home, right?

WHOA, not so fast!

Actually, this sort of injury can be devastating, even life-altering, and similar cases have led to some enormous judgements and settlements in the past! The reason? This mechanism of injury can easily lead to a severe infection of the bones of the foot (metatarsal osteomyelitis). Far more should be done to adhere to the standard of care than just yanking out the nail. First of all, the clinician should ask about, should clearly document in the medical record, and should appropriately act upon the following specific features:?

The Nail Itself? - Was the nail clean and bright, or was it grossly dirty, rusty, or otherwise contaminated??

A 3-view X-ray series of the foot is a minimum standard in this sort of case and should be done to look for even tiny metal flakes or rust in the wound, or for any nick or impression on the metatarsal bones. Any of these features might actually require a surgical exploration of the wound tract!?

Footwear - What type of footwear was penetrated by the nail??

There is a well known association between nail puncture wounds that go through sneakers or other rubber soled shoes and a resulting very unusual type of bone infection: osteomyelitis with the bacterium Pseudomonas aeruginosa. Some experts believe that this mechanism of injury can carry a small plug of rubber from the shoe into the wound tract. In this case, the treating clinician might be required to anesthetize the foot and physically “core out” some tissue to prevent severe infection. Furthermore, Pseudomonas species have resistance to many classes of antibiotics and effectively treating these infections requires the use of specific antibiotics that would not be the obvious choice for less skilled or less knowledgeable clinicians.?

Health Status - Finally, is the patient diabetic? Are they immunocompromised? Do they have poor peripheral circulation? Have they previously lost their spleen? A history of certain health conditions are known to put people at much higher risk for infections, especially from Pseudomonas bacteria.

Med Mal Takeaway - Treating clinicians who get these things wrong can easily set their patient up for a bone infection in the foot which will require prolonged antibiotic treatment, surgical care, and sometimes even amputation. These infections can be life-altering and can lead to significant disability and medical costs.?

Personal Injury Takeaway - It might seem like the case of a client who stepped on a nail that was haphazardly left by another party is simple, but there may be far more extensive medical costs than a simple ER visit.?

Stay tuned for more Weird Case Wednesdays. As always, if I can be of any help in your cases, please email me at [email protected] or call me at (650) 649-5352.?