osteomyelitis Archives - Jeffrey Sterling, MD

Straight, No Chaser: Step on a Nail? What Happens Next?

What would you do if you stepped on a nail? What if the nail was rusty? Does it make a difference if you were wearing shoes? Is stepping on a nail dangerous? Why does everyone pronounce tetanus “teknus?” For the answers to these questions (well maybe not the last one) and more, read the rest of this Straight, No Chaser!
It’s an interesting thing that so many nails are allowed to stay on the ground until they become rusty. One would think either they’d be picked up or that you wouldn’t be walking around barefooted in unknown areas. We’ve discussed puncture wounds previously, and stepping on a nail is an example of a puncture wound. However, there are some important considerations that make it worthwhile to discuss.

What should you do if you step on a nail?
Assuming the nail isn’t stuck in your feet, clean your foot vigorously. If the nail is superficially struck in your foot, it’s likely you will have reflexively yanked it out. That’s ok as long as the wound isn’t significantly bleeding at the time.
It’s prudent that you call your physician for next instructions, but in most cases you’ll be directed to come to the emergency room.

What’s the issue?
There is no one issue. There are several potentially significant consequences of stepping on a nail.

If the skin was sliced instead of punctured, that’s a laceration, which will need to be addressed.
It makes a huge difference if you were wearing shoes or not, and not in the way you might think. Stepping on a rusty nail is a much more dangerous proposition if you did so while wearing rubber soles. One of the more dangerous bacteria we have to deal with (named Pseudomonas) thrives in rubber. The puncture from grass or ground through the sole of a rubber shoe into your foot may plant this bacteria superficially or deeply into your foot, causing one (or several) of many different types of infections.
Rusty nails can produce tetanus, which is almost always fatal. This is why you get immunized at least every decade for this disease. You wouldn’t want your worse enemy to suffer a death from tetanus (at least I’d hope not).

What kind of infections can you get from this?
Skin infections are common after puncture wounds involving nails, and can include the following:

Cellulitis – a straightforward infection of the skin
Abscesses – those walled-off “pus pockets” that sometimes require incision and drainage to make it go away
Osteomyelitis – the bones deeper into the foot can actually become chipped and/or infected as well

These are significant wounds, especially if rubber soles are involved, and they may even require surgery to clean the area. In some instances (especially when you have certain risk factors) skin ulcerations (breakdown of the skin) can occur, making severe infection more likely. In some of these instances, foot amputation is necessary.
In addition to wearing rubber-soled shoes at the time of the injury, these other conditions place you at risk for a worse outcome.

Cancer
Diabetes
Malnutrition
Reduced immunity
Smoking history

The infections associated with nail-induced puncture wounds are potentially serious and hard to treat. Patients sometimes end up hospitalized with weeks and sometimes months of treatment with antibiotics.
In case you think the take home message is it’s better not to wear shoes or sandals when walking through the house, grass or sand, you’re partially correct. My best advice to you is look before you weep.
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Straight, No Chaser: Swimmer's Ear (Acute Otitis Externa)

It’s that time of year. Whether you’re getting purified in Lake Minnetonka (obscure pop culture reference alert) or your local watering hole, as the weather warms, a lot of people end up with swimmer’s ear. This is the time of year when certain bacteria and other organisms have their day in the (dirty) water and are waiting to infect you.

Acute otitis externa (aka swimmer’s ear) is an infection or inflammation of the outer ear and ear canal. It is a different infection that those inner ear infections that kids seem to get all the time; that would be otitis media. Those two infections may occur at the same time, although it isn’t likely. Otitis externa isn’t just caused by polluted water; anything that causes inflammation or infection can cause it. For example, otitis externa may be a consequence of a bite or scratch to the ear or a foreign body in the ear (yet another reason to inserting cotton swabs or other objects into the ear).

If you develop acute otitis externa, you’ll know it. Symptoms include itching and pain, pus-like drainage from the ear and hearing loss. Unlike those inner ear infections, in otitis externa you may notice the pain is pronounced when you pull on the outer portion of the ear.
The interesting thing about treatment of otitis externa is it isn’t that complicated and usually gets better promptly. What is complicated about it is failure to get treated can result in some serious complications. Treatment is accomplished by giving antibiotic eardrops. Some of you who have have swimmer’s ear may recall the use of an ear wick to facilitate the drops making their way to the end of the ear canal. Other treatments may include oral antibiotics, topical steroids, pain medication and vinegar eardrops (the acid in the vinegar works to prevent further growth of bacteria).
Regarding you placing vinegar in the ear yourself: it is often stated that mixing one drop of white vinegar with one drop of alcohol and placing this into the ear can help. My advice to you is regardless of any home remedies or over-the-counter measures you take, you should get evaluated because of the risk of complications if not adequately treated. Placing any object – even fluid – in your ear presents additional risks, particularly in those rare instances in which the eardrum has ruptured. I subscribe to the old adage that you shouldn’t place anything in your ear smaller than your elbow.

Regarding complications, because of the aggressive nature of the bacteria causing acute otitis externa (named Pseudomonas), things can take a dramatic turn for the worst.

Infectious acute otitis externa may spread to other areas including the skull bone, causing an infection known as osteomyelitis.
In those with reduced immunity, diabetics or the elderly, the infection may become severe and life threatening. This is called malignant otitis externa.

Protecting yourself from swimmer’s ear isn’t that difficult. It mainly requires you to think about the possibility, mostly when you’re getting water in your ears.

Avoid swimming in polluted water.
Avoid placing any objects such as cotton swabs in your ears. It’s ok and helpful to use earplugs when swimming.
Ensure water doesn’t get into your ears when bathing, shampooing or showering. Thoroughly dry the ear after exposure to moisture.

We welcome any questions you may have.

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