“One of the
most important things that a parent should do if their child steps
on a nail or any other sort of object that penetrates the foot,
is remember that there’s risk for damage to tissues underneath
and that there’s a risk for infection…so one of the
first things you may need to do is clean the wound and apply pressure
and then seek medical attention as quick as you can.”

–Mike Ziegler, MD, emergency pediatrics, Children’s Healthcare of Atlanta

When kids are outside playing in their bare feet and step on a nail,
an immediate concern is tetanus. But it turns out that they might be in
even more danger if they were wearing tennis shoes.

“Was he wearing shoes at the time or was he barefoot?” asks
Dr. Mike Ziegler, Children’s Healthcare of Atlanta.

Last night eight-year-old Jacquai stepped on a nail. He recently
had his booster shots, so tetanus is not the issue. “And
it went through the bottom of his shoe and came out the top?” the
doctor asks.

Jacquai was wearing tennis shoes. “These shoes will often
grow an organism called pseudomonas, which if it gets into the
tissues and near the bone can actually cause a nasty bone infection
called osteomyelitis,” the doctor explains.

Pseudomonas bacteria grows in moist, warm environments like soil
and sweaty tennis shoes.

The fear is that he’s already showing signs of infection. “The
thing I’m a little bit concerned about is that the toe is
already somewhat swollen,” explains Dr. Ziegler, “and
that there’s already a little bit of milky discharge down
there where the nail went in, so I really want to try to prevent
this from becoming somewhat worse.”

Pseudomonas is very resistant to antibiotics, but there is one
that should work, Cipro. “It’s one of the few antibiotics
that we can give by mouth that will actually help to treat and
deal with a pseudomonas infection,” he tells the family.

Jacquai will go home, but he’s not out of the woods yet. “It’s
very important that parents understand also that the wound may
look clean, there may be no fever, but injury down deep inside
the tissues could be leading to a smoldering infection that can
destroy bone,” warns Dr. Ziegler.

He will need to follow-up with his regular doctor in a few days
to make sure the infection is not getting worse.

Infections can develop as the result of germs getting into an injured
area on the foot. According to experts at WebMD, be on the lookout for
the following signs if you suspect inflammation or infection of the toe,
foot or ankle area:

• Increased pain, swelling, redness or warmth around the affected
  area
• Red streaks extending from the affected area
• Drainage of pus from the area
• Swollen lymph nodes in the groin
• Fever of 100°F (37.78°C)
  or higher

The feet contain 52 individual bones – that’s 25 percent of
the bones in the entire body! There are also muscles, tendons, ligaments,
arteries, veins and nerves. It is especially important to ensure your child’s
feet are healthy because these bones, muscles and ligaments are still developing
and are very susceptible to any external stresses. The Doctors of Pediatric
Medicine have created the following tips to help maintain your child’s
healthy feet:

• Do not bind covers over your baby’s feet. It restricts movement
  and can retard normal development.
• Provide an opportunity for exercising the feet. Lying uncovered
  enables the baby to kick and perform other related motions that
  prepare the feet and legs.
• Change baby’s position several times a day. Lying too long
  in one spot, especially on the stomach, can put excessive strain
  on the feet and legs.
• Once children begin to walk, their feet should be examined
  by a podiatrist.
• Check shoe size periodically to ensure that feet have room
  to grow, and watch for excessive shoe wear in any one area.
• Do not hand down shoes from one child to another. Each pair
  of feet has its own requirements.
• Walking is the best of all foot exercises. Observe your child’s
  walking habits. If you see toeing-in or toeing-out, knock knees,
  or other gait problems, professional attention is needed.
• Night leg cramps are usually due to foot fatigue and muscle
  imbalance. So-called “growing pains” frequently are
  symptoms of abnormal foot mechanics.
• Remember that lack of complaint by a youngster is not a reliable
  sign. The bones of growing feet are so flexible that they can
  be twisted and distorted without the child being aware.
• Be very careful about employing home remedies against fungus
  infections or warts on the foot. Strong preparations can burn
  or otherwise hurt the skin.
• Consult a podiatrist whenever you have questions about your
  child’s foot health.

“So what brought you to the hospital today, Marvin?” asks Dr. Kathleen Nelson as she walks into the hospital room. He was playing on his grandmother’s back porch when he stepped on a rusty nail explains Marvin’s mom.

“When we looked at his foot there was a clear area around the puncture wound that looked like there was some infection in there,” says Dr. Nelson. “And so what I see here is a little redness right around where it entered and I see a streak up your foot,” she explains to Marvin.

“Were you wearing shoes when you were stepping on the nail?” Dr. Nelson asks. Marvin nods his head yes. But they weren’t just shoes, Marvin was wearing sneakers and that can be a problem. “We do particularly worry about nails that go through sneakers. Because the foam sole of the sneaker seems to be a good breeding ground for another kind of germ…pseudomonas,” explains the doctor, “which can lead to infection in the bone.”

For now the treatment is simple and predictable- a tetanus shot and antibiotics in case of a staph or strep infection. “But we want you to be very careful and watch him closely over the next week to ten days, because if he should develop increasing pain or if his fever doesn’t go away, or if the foot starts hurting more or swelling more, we need to see him again…and we’d have to treat that with something stronger than the medicine we’re gonna give him today…” warns Dr. Nelson, “hope you feel better.”

For most children, a trip to the doctor for a shot is a nerve-wracking experience. It is, however, a necessary step to prevent particular diseases and illnesses. This is especially true for Td booster shots, which protect individuals from two serious diseases – tetanus and diphtheria. Your child may be given a tetanus shot if he/she has stepped on a nail or been cut handling a rusty object, especially if it has been over five years since the last shot. Experts recommend getting a booster shot every 10 years throughout an individual’s lifetime. So what is tetanus? Experts at Caring for Kids have developed the following list of facts regarding the disease:

• Tetanus is commonly known as lockjaw.
• It is caused by germs (bacteria) that live in dirt and dust.
• If the tetanus germ gets into an open cut on the body, poison from the germ can spread to the nerves and then into the muscles. Muscles may lock in one place or go into spasm (get very tight), which is very painful.
• In most cases, the first muscles affected are in the jaw. Infected individuals may not be able to swallow or open their mouths.
• If the poison gets to the muscles that help the breathing process, suffocation is a very real possibility.
• The main treatment for tetanus is drugs (antibiotics) to kill the germs. Drugs to control the muscle spasms are also available.
• People who survive tetanus may have long-lasting problems with speech, memory and thinking.
• People who survive can still get tetanus again. For this reason, they should get the vaccine to protect them in the future.

If you believe your child is at risk for developing tetanus, contact your physician immediately. According to experts at the Children’s Hospital of Pittsburgh, your doctor will prescribe treatment for your child based on:

• Your child’s age, overall health and medical history.
• The extent of the disease.
• Your child’s tolerance for specific medications, procedures or therapies.
• The expectations for the course of the disease.
• Your opinion or preference.

Treatment for tetanus may include:

• Medications (to control spasms).
• A thorough cleansing of the wound.
• A course of tetanus antitoxin injections.
• A tracheotomy (a breathing tube inserted surgically in the windpipe) in severe cases where respiratory problems are present.

Caring for Kids
Children’s Hospital of Pittsburgh
KidsHealth