Puncture Wounds

Millions of Americans across the country are involved in athletics and recreational activities on a daily basis. Inherent to many of these endeavors is the risk of trauma to the dermatologic system. The most frequent types of mechanical skin injuries are abrasions, lacerations, and puncture wounds. The majority of skin trauma (approximately 50%) involves the head and neck, with the second most common site of injury being the upper extremities (approximately 35%). This entry discusses puncture wounds and will review the common histological and anatomic structures relevant to the skin, the approach to evaluation of a puncture wound, the management of these wounds, and the complications of these injuries.

Puncture wounds are defined as a wound to the skin in which the opening is relatively small as compared with the depth. These wounds are most often caused by a narrow pointed object, such as a shard of wood, glass, or metal. There are myriad sporting activities that may cause puncture injuries to the skin. Some of the common puncture wound injuries in sports are caused by metal cleats, fishhooks, and accidental tooth penetration. There are also case reports of hockey sticks breaking and causing wooden or composite puncture wounds with retained foreign bodies. Other, more rare but potentially devastating puncture wounds seen in hockey are deeply penetrating wounds from skates involving the axillary or carotid arteries. Surfing and open-water swimming carry the risk of puncture wounds caused by stings from aquatic creatures such as needlefish or stingrays. Fencing injuries can also be quite dangerous and have included puncture wounds through the chest wall, causing a collapsed lung, and wounds to the neck, causing laryngeal injury. Many of these activities have protective equipment designed to minimize puncture injuries, but it is the participants who must ensure the proper use and maintenance of equipment to fully protect themselves from puncture wounds and their potential complications.

The first step to understanding and treating these wounds is to briefly review skin anatomy. Skin is composed of three histologically and functionally distinct layers. The outermost layer is the epidermis. This layer serves as the first line of defense against pathogenic organisms, maintains the separation between our fluid-filled bodies and the outside environment, and protects against destructive ultraviolet (UV) rays from the sun. This layer can vary in thickness from 0.075 millimeters (mm), for example, along the eyelid, to 0.6 mm, as in the soles of the feet. The next layer is the dermis, which contains a variety of structures, including sensory nerves, various oil and sweat glands, very small arteries and veins, and finally hair follicles. These structures are anchored in a dense connective tissue called collagen. Finally, there is the subcutaneous layer, which is composed mostly of fatty tissue, which serves to insulate and mechanically protect the underlying structures. When grossly viewing these layers, the epidermis is the thin fleshy outer layer, followed by the dermis, which is whitish and denser appearing. Last, the subcutaneous layer is yellow with globules of fat. These layers can usually be visualized when evaluating puncture wounds.

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