P u n c t u re Wo u n d s
o f t h e Fo o t
Brent D. Haverstock, DPM
KEYWORDS
Foot Puncture Lower extremity Trauma
Puncture wounds of the foot, with or without a retained foreign body, are a common
presentation to the emergency department, urgent care center, or physician’s office.
This injury may occur in several settings, ranging from a simple puncture wound
occurring at home to a more dramatic work-related injury. The outcome from puncture
wounds and retained foreign bodies often depends on the severity of the injury, the
penetrating object, and the medical status of the individual who sustains the injury.
Most individuals who sustain a puncture wound never seek medical care. They treat
the wound at home and are fortunate that complications do not occur. Others may
develop an infection or realize that something is wrong with their foot as a result of
the injury, such as a tendon laceration resulting in loss of function or a nerve injury
rendering an area of the foot numb. Although it is difficult to determine the incidence
of pedal puncture wounds, it has been suggested that 10% of such injuries result in
a complication.1 Complications may include a soft tissue infection, deep abscess,
osteomyelitis, reactive inflammation, pyogenic granuloma, epidermal inclusion cyst,
tendon laceration/dysfunction, and nerve injury.
When an individual presents with a complication related to a puncture wound, the
treating physician must carry out a comprehensive history and physical examination
and develop an appropriate treatment plan. Delay in treatment may result in significant
morbidity or mortality, particularly in the immunocompromised individual (Fig 1).
EPIDEMIOLOGY
Pedal puncture wounds can occur in a broad array of circumstances. Most plantar
puncture wounds are caused by nails; however, glass, wood, or other metal objects
can be the source of the puncture. More than 7% of patients with lower extremity
trauma who presented to an emergency department in one survey had plantar punc-
ture wounds.2 These wounds occurred more often in the months of May to October;
however, in the middle of winter in North Dakota, the injury may involve a nail at
a construction site, whereas in Florida on the same day, it may be caused by glass
on a beach. Superficial wounds generally heal without complications, but deeper
Section of Podiatric Surgery, University of Calgary, Faculty of Medicine, Peter Lougheed Centre,
3500 26 Avenue NE, Calgary, Alberta T1Y 6J4, Canada
E-mail address: brent.haverstock@albertahealthservices.ca
Clin Podiatr Med Surg 29 (2012) 311–322
doi:10.1016/j.cpm.2012.02.002 podiatric.theclinics.com
0891-8422/12/$ – see front matter Ó 2012 Elsevier Inc. All rights reserved.
312 Haverstock
Fig. 1. A 27-year-old man presents to emergency department with a puncture wound to the
right foot. The patient was vague as to the nature of the injury.
penetration or a retained foreign body from the puncture is a risk factor for more
serious infection. Puncture wounds of the metatarsophalangeal joints or heel and
surrounding tissue often penetrate deeper because of the weight-bearing function
of these areas of the foot.
The site of the injury on the plantar aspect of the foot has shown variable rates of
complications. Patzakis and colleagues3 evaluated the site of injury on the plantar
aspect of the foot to determine variables in complication rates. They divided the
foot into 3 zones. Zone 1 extends from the neck of the metatarsals to the end of the
toes. Zone 2 includes the area between the distal aspect of the calcaneus to the necks
of the metatarsals. Zone 3 is occupied by the calcaneus. In their study, they evaluated
the site of injury, condition of the nail, and type of footwear in 36 inpatients and 34
outpatients with nail puncture wounds to the foot. Of the 36 inpatients, 34 (94%)
had pyarthrosis, osteomyelitis, or both. Of the 36 inpatients, 35 (97%) had deep punc-
ture wounds in zone 1. In contrast, only 6 of 34 (18%) outpatients had injury to this
area. Tennis shoes were shown to predispose to infection with Pseudomonas aerugi-
nosa. Based on their findings, they suggested that early hospital admission should be
considered for all patients with deep puncture wounds located in zone 1 and for
patients who give a history of bone penetration in zone 2 or 3 at the time of injury.
Puncture wounds are common in children who enjoy running around outside uncon-
cerned about the environment they are running in. In a review of 44 children admitted
to hospital for puncture wounds of the foot, cultures were positive for osteomyelitis in
7 patients (16%), all involving the forefoot (P<.04). The most common pathogen in soft
tissue infections was Staphylococcus aureus.4 The most common pathogen in osteo-
myelitis was P aeruginosa. There was no significant difference in the prevalence of
Puncture Wounds of the Foot 313
osteomyelitis and soft tissue infection based on footwear. There were no cases
of osteomyelitis encountered among barefoot children (P<.04). In 10 cases (83%), P
aeruginosa infection (both soft tissue and bone) occurred while the patients were
wearing tennis shoes (P<.04).
An evaluation of 96 patients who sustained a nail puncture injury of the foot through
a rubber-soled shoe showed that 36 (37.5%) were treated conservatively and 60
(62.5%) were treated surgically.5 Of those treated surgically, 15 (25%) had a foreign
body extracted during the procedure. The surgical group had a longer period of
time from injury to hospital admission than did the nonsurgical group (5.0 6.8
days vs 2.7 3.8 days, P<.05). Treatment success was observed in 91 (94.8%) of
the patients, and the median lag time before admission for the less successfully
treated group was longer than that for the successfully treated group (10 days vs 2
days, P<.002). The less successfully treated group was more likely to receive antibi-
otics in the community before hospitalization (100.0% vs 47.2%, P<.06), and was
more likely to be diabetic (40.0% vs 9.9%, P<.10).
In a retrospective review of the charts of 80 children admitted to the hospital with
plantar punctures, 59 had superficial cellulitis, 11 had retained foreign bodies, and
10 showed osteomyelitis and/or septic arthritis. There was a significant presentation
delay in patients from the second and third groups. The most common organisms
were S aureus or group A Streptococcus. Of the 80 children, 34 were treated surgically
and 46 were treated with antibiotic therapy alone. All patients with osteomyelitis and
septic arthritis were reexamined; at follow-up, all but 1 were asymptomatic apart from
residual radiologic sequelae in 4 (Fig. 2).6
Most of the research to date has centered on puncture wounds of the diabetic foot.
Researchers in Montego Bay, Jamaica, performed a study on the natural history of
Fig. 2. A pencil is removed in the operating room.
314 Haverstock
closed pedal puncture wounds in diabetics. A survey was conducted via an
interviewer-administered questionnaire on 198 adult diabetics residing in the parish
of St. James, Jamaica. The prevalence of a history of at least 1 closed pedal puncture
wound since diagnosis of diabetes was 25.8%. Of 77 reported episodes of closed
pedal puncture wound among 51 participants, 45.4% healed without medical inter-
vention, 27.3% healed after nonsurgical treatment by a physician, and 27.3% required
surgical intervention ranging from debridement to below-knee amputation. The neuro-
pathic foot and the site of the injury (the plantar forefoot) were the variables associated
with increased risk of surgical intervention. This study showed that 72.7% of wounds
healed either spontaneously or after nonsurgical treatment. This finding means that
routine, nonselective surgical intervention for preinfected closed pedal puncture
wounds in diabetics is not justified. However, the subset of patients with an anesthetic
foot and a wound on the sole of the forefoot should be marked for intensive surveil-
lance and early surgical intervention if infection occurs.7
Armstrong and colleagues8 reviewed the hospital course of 77 diabetic and
69 nondiabetic subjects who had incision, drainage, and exploration of infected punc-
ture wounds of the foot. Diabetics were 5 times more likely to have multiple operations
and 46 times more likely to have a lower extremity amputation than nondiabetics. The
interval from injury to surgery was significantly longer in diabetics than in nondiabetics.
Total lymphocyte count and hemoglobin, hematocrit, and albumin values were signif-
icantly lower in diabetics than in nondiabetics. Diabetic amputees had a higher prev-
alence of nonpalpable pulses, nephropathy, neuropathy, and osteomyelitis compared
with diabetic nonamputees.8
Lavery and colleagues9 evaluated the incidence of osteomyelitis in individuals with
diabetes who sustained a puncture wound of the foot. The study included 45 men and
21 women who were admitted to the hospital for a foot infection precipitated by
a puncture wound. Twenty-two (33%) patients had osteomyelitis based on either
a positive bone culture or pathology report. Forty-four patients had soft tissue infec-
tions. Patients with osteomyelitis received medical treatment later than patients with
soft tissue infections. Significant differences were identified when comparing the
time from injury until hospitalization and surgical debridement, and the interval from
professional medical evaluation until hospitalization and surgical debridement. The
delay in seeking or receiving medical care may dramatically alter the morbidity asso-
ciated with the puncture wound. Patients with punctures involving the forefoot and
patients who wore shoes at the time of the injury were more likely to develop osteo-
myelitis than patients who had rearfoot injury and patients who were barefoot at the
time of injury.9
PATIENT PRESENTATION
Most individuals presenting with a puncture wound show a benign looking injury that
may be difficult to see. The most common presentation of a puncture wound is a small
entry point with irregular skin margins and local ecchymosis. Signs of hemorrhage may
also be present. Some may have a more dramatic-appearing injury with a visible
foreign object penetrating the foot. Many patients who seek medical care do so
because of pain, concerns regarding their tetanus status, or for treatment of a minor
soft tissue infection. Patients who have delayed seeking medical care or those with
a neuropathic foot often present with a significant wound including local edema and
erythema, wound drainage, ascending cellulitis, and lymphadenopathy. The clinical
course following the injury may have been uneventful but, in 48 to 72 hours, the picture
changes rapidly to the point at which a significant infection is well established (Fig. 3).
Puncture Wounds of the Foot 315
Fig. 3. A 44-year-old man with methicillin-resistant Staphylococcus aureus and hepatitis C
admitted to hospital with cellulitis of the leg. Examination reveals a puncture wound
beneath the fifth metatarsal head.
CLINICAL EVALUATION
When evaluating an individual who presents with a pedal puncture wound, it is impor-
tant to complete a thorough history before evaluating the foot. It is important to obtain
the following information:
(1) When the injury occurred; has it been just a few hours or have a couple of days
passed since the puncture wound occurred?
(2) Was the individual wearing any form of footwear at the time of the injury and
what was the environment in which the injury occurred?
(3) Did the individual see what the penetrating object was and did they remove any
object? If so, did they remove it in toto and do they have it with them?
It is imperative to update the patient’s tetanus status to establish whether the indi-
vidual received vaccination with tetanus toxoid and when they received their last
booster vaccine.
When evaluating the foot following a puncture wound, the examiner must first carry
out a vascular and neurologic examination. Palpation of the dorsalis pedis and poste-
rior tibial arteries provides a baseline as to the patient’s vascular status. If the pulses
are nonpalpable, then a vascular consultation will be needed if there is serious infec-
tion and surgical intervention is considered. Patients with compromised circulation
also require a vascular consultation, even if surgery is not considered necessary. A
neurologic evaluation helps to determine whether there is a nerve injury from the pene-
trating object. Loss of sensation distal to the injury site is a sign that a nerve has been
316 Haverstock
damaged by the object. If it seems that a large nerve is involved, rendering a substan-
tial portion of the foot insensate, microsurgical nerve repair should be performed. This
condition must be differentiated from the insensate foot in a patient with diabetic
neuropathy. The digits are assessed for mobility to determine whether a tendon lacer-
ation has occurred. Careful attention is needed to differentiate the long flexor tendons
from the intrinsic flexors of the foot.
The entry site of the puncture is then evaluated. The margins of the skin are
assessed for the appearance of jagged or smooth skin edges. The site is inspected
for any signs of a retained foreign body. The margins of the wound are gently palpated
to again determine whether a retained foreign body is present. The wound is inspected
for drainage, malodor, localized erythema, edema, and ascending cellulitis. Crepitus
on palpation of the soft tissue may indicate a deep infection with abscess or subcuta-
neous gas.
DIAGNOSTIC IMAGING
The first step is to obtain plain film radiographs of the foot (Fig 4). Metal objects such
as pins and nails are easily visible. Glass may be visible if it contains lead or if the frag-
ment is large enough, as will wood splinters that are large enough to cast a shadow on
the radiograph. Plastic is not seen (Figs. 5 and 6).
Radiographs in the patient with diabetes who has sustained a puncture wound are
important to assist in determining whether there is any septic sequelae of the puncture
wound.10 As discussed earlier, patients with diabetes frequently delay seeking
medical care. The sepsis that occurs from puncture wounds is often deep to the
deep fascia and, because the sole of the foot has thick skin and subcutaneous fibrous
septae, crepitus is not as easily appreciated as at other sites. Also, the erythema of the
inflammatory response is often minimal in subfascial sepsis. Plain film radiographs
may show deep infection, a retained foreign body, or osteomyelitis.
If the patient indicated during the history that the object was thought to be some-
thing that is not seen on a radiograph or they are not sure what caused the puncture
wound, then further imaging studies are required. Ultrasound is an accurate test for
detection of foreign bodies and to assess potential complications such as tendon
laceration.11,12
Researchers compared the sensitivity for detecting foreign bodies among conven-
tional plain radiography, computed tomography (CT), and ultrasonography in in-vitro
models. Seven different materials were selected as foreign bodies, with dimensions
Fig. 4. Radiographs reveal a retained foreign body.
Puncture Wounds of the Foot 317
Fig. 5. The foreign body is removed.
Fig. 6. The foreign body was a piece of glass.
318 Haverstock
of approximately 1 by 1 by 0.1 cm. These materials were metal, glass, wood, stone,
acrylic, graphite, and Bakelite. These foreign bodies were placed into a sheep’s
head between the corpus mandible and a muscle in the tongue, and in the maxillary
sinus. Conventional plain radiography, CT, and ultrasonography imaging methods
were compared to investigate their sensitivity for detecting these foreign bodies. It
was determined that metal, glass, and stone can be detected with all the visualization
techniques used in the study in all of the zones. In contrast, foreign bodies with low
radiopacity that could be detected in air with CT became less visible or almost invisible
in muscle tissue and between bone and muscle tissue. The performance of ultraso-
nography for visualizing foreign bodies with low radiopacity is better than CT.13
WOUND MICROBIOLOGY
Numerous studies have described the bacterial cause of infections following puncture
wounds of the foot. The most common gram-positive organisms isolated in these
wounds are S aureus, a-hemolytic streptococci and Staphylococcus epidermidis.
Gram-negative organisms isolated from these wounds have included Escherichia
coli, Proteus, and Klebsiella species.2,4,8,9 Miscellaneous organisms have been iso-
lated from puncture wounds occurring in brackish water. Brackish water is water
that has more salinity than fresh water, but not as much as seawater. It may result
from mixing of seawater with fresh water, as in estuaries. Organisms isolated from
wounds occurring in such an environment include Aeromonas hydrophila and Myco-
bacterium marinum.14
Pseudomonas infection is a concern in puncture wounds of the foot. P aeruginosa is
a common gram-negative, aerobic, rod-shaped bacterium that is found in soil, water,
and skin flora. Pseudomonas is the most common organism responsible for osteomy-
elitis secondary to puncture wounds. A relationship has been documented between
rubber-soled shoes and pseudomonal osteomyelitis.1,15,16 When a nail or other object
penetrates the shoe and then the foot, it inoculates the puncture wound with the pseu-
domonal organisms found on the shoe.
Management of Puncture Wounds
The management of puncture wounds requires a high level of clinical suspicion
because the appearance of these wounds is often benign. The wound should not
be dismissed as insignificant. A delay in providing adequate treatment is a factor in
the development of complications following a puncture wound of the foot. The
approach to managing these wounds depends on whether or not the presenting
wound is infected.
MANAGEMENT OF UNINFECTED WOUNDS
Tetanus Immunization
Tetanus is a medical condition characterized by a prolonged contraction of skeletal
muscle fibers. The primary symptoms are caused by tetanospasmin, a neurotoxin
produced by the gram-positive, rod-shaped, obligate anaerobic bacterium, Clos-
tridium tetani. Infection generally occurs through wound contamination and often
involves a cut or deep puncture wound. As the infection progresses, muscle spasms
develop in the jaw, hence the term lockjaw. Infection is preventable with proper immu-
nization and by postexposure prophylaxis.17
Tetanus can be prevented by vaccination with tetanus toxoid. The US Centers for
Disease Control and Prevention recommend that adults receive a booster vaccine
every 10 years. If patients presenting with pedal puncture wounds cannot recall
Puncture Wounds of the Foot 319
when they last received a booster, one should be administered.18 In children less than
7 years of age, the tetanus vaccine is often administered as a combined vaccine that
also includes vaccines against diphtheria and pertussis (DPT [diphtheria-pertussis-
tetanus]/DTaP [diphtheria-tetanus–acellular pertussis]). For adults and children more
than 7 years of age, the Td (tetanus and diphtheria) or Tdap (tetanus, diphtheria,
and acellular pertussis) vaccines are commonly used.19
Wound Care
In patients who present for medical treatment within 6 hours of the injury and have
a superficial puncture wound with no evidence of a retained foreign body, the wound
can be probed gently and irrigated with normal saline solution. Jagged or irregular skin
edges must be excised. If necessary, this can all be performed under a local infiltrative
block. The wound is covered with a sterile dressing that is changed every 6 hours for
the first 48 hours, watching for signs of infection. After 48 hours, the dressing is
changed daily until the wound is healed.
When a patient has delayed seeking medical treatment or the wound has sustained
a deep penetrating injury with significant clinical contamination present, incision and
drainage with exploration and irrigation is required. Under a local infiltrative and
a regional foot block, the foot is cleansed and prepped. An ankle pneumatic tourniquet
is used. The wound must be aggressively debrided of all necrotic and nonviable soft
tissue while sharply incising jagged skin edges to decrease the chance of skin
necrosis. A deep soft tissue culture is taken. The wound is partially closed over a Pen-
rose drain. A sterile dressing is applied and the patient is instructed to maintain non–
weight bearing with crutches until instructed otherwise. The dressing is changed at
48 hours and the wound evaluated. At this time, the drain is removed. The patient is
instructed to maintain non–weight bearing until the wound has healed and ambulation
can be performed without any pain.
Foreign Body Removal
If the puncture wound has a retained foreign body, consideration must be given to
removal of the object. If the object, such as a needle, nail, or gravel, is superficial,
removal is simple. The same steps as described for management of a delayed or
contaminated wound should be performed along with removal of the object.
A deeper retained foreign body requires intervention under general or spinal anes-
thesia. A thigh tourniquet allows easier manipulation of the extremity when using diag-
nostic imaging such as fluoroscopy. When using fluoroscopy, triangulation is often
useful in determining the location of the object. Real-time, live imaging is also used
as the surgeon attempts to grasp the object. In cases in which the foreign body is
not radiopaque, intraoperative ultrasound is helpful in locating and retrieving the
object. Irrigation may also flush the object loose from the surrounding tissue.
Antibiotic Prophylaxis
Superficial puncture wounds without clinical contamination or necrotic tissue can be
managed without prophylactic antibiotic coverage. The wound is evaluated every 6
hours for the first 48 hours and, if any signs of infection develop, antibiotics should
be started.
In deeper wounds with delayed presentation and presence of contamination and
necrotic tissue, antibiotics should be started once the wound has been managed
and cultures taken. If the patient has an intravenous site, the first dose can be admin-
istered via this route. A broad-spectrum antibiotic for coverage of gram-positive and
gram-negative organisms and P aeruginosa should be used. Oral ciprofloxacin 500 mg
320 Haverstock
twice daily or levofloxacin 500 mg daily should be prescribed for a 10-day course. If
the patient has an allergy or cannot tolerate either of these drugs and there is strong
concern for the development of infection, then antipseudomonal penicillin or amino-
glycoside may be considered. This requires outpatient intravenous therapy for a few
days until the physician is satisfied that a clinical infection has not developed.
MANAGEMENT OF INFECTED WOUNDS
All patients who present with a foot infection secondary to a puncture wound must be
considered a medical emergency. As described earlier, a comprehensive history and
physical examination must be performed. Baseline laboratory tests, such a complete
blood count, erythrocyte sedimentation rate, and C-reactive protein should be
completed. Plain film radiographs should be obtained. The patient is taken to the oper-
ating room where, under general or spinal anesthesia and with a thigh tourniquet, an
incision and drainage procedure is performed. All necrotic tissue is sharply excised
and the wound thoroughly evaluated for a retained foreign body. One author advocates
creating a small dorsal skin incision, converting a deep track into a tunnel through
which irrigation and curettage can be completed. With irrigation of the wound, a foreign
body may be removed.20 Once the wound has been adequately explored, debrided,
and irrigated, deep soft tissue cultures are obtained. If preoperative radiographs raise
suspicion of an osseous infection, a bone culture should be obtained. The decision to
violate the bone should be based on the length of time the infection has been present
and radiographic signs of infection such as periostitis, osseous destruction, or lucency.
If unsure, further diagnostic tests can be performed following the initial surgical incision
and drainage. The wound is lightly packed open and the packing changed every
12 hours. If osteomyelitis is suspected but bone cultures were not taken during the
initial procedure, a 3-phase bone scan is completed. If this is negative, then the soft
tissue infection only needs to be managed. If the 3-phase bone scan is positive, the
next step is to order a white cell labeled bone scan. Again, if this is negative, the soft
tissue infection only needs to be managed. If the white cell bone scan is positive,
a bone culture can be taken at the time of the secondary debridement and closure.
Initially, the patient is started on the appropriate broad-spectrum antibiotics, which
are narrowed as culture results become available. Antipseudomonal penicillins, ticar-
cillin and piperacillin (200–300 mg/kg/d in divided doses, every 4–6 hours), provide
excellent gram-positive and gram-negative organism coverage. Third-generation
cephalosporins, ceftazidime (1 g intravenously [IV] every 8–12 hours) and cefopera-
zone (1–2 g IV every 12 hours), also provide Pseudomonas, gram-positive, and
gram-negative coverage. Aminoglycosides also provide Pseudomonas coverage
and are an option for patients with a penicillin allergy. In adults, intravenous gentamicin
is started at 2 mg/kg followed by 3 to 5 mg/kg/d in divided doses every 8 hours. In chil-
dren, the dosing of gentamicin is 1 to 3 mg/kg/d every 8 hours. All antibiotics must be
appropriately monitored and dosed for renal disease and potential toxicity.
Once the infection starts to respond to local wound care and antibiotic therapy,
planning for a secondary procedure begins. Between 5 and 7 days should be allowed
for the initial infection to respond to antibiotic therapy before performing a delayed
primary closure. If a resistant strain of microorganism is isolated, this secondary
procedure may be delayed. If it seems that the skin margins will not reapproximate,
the use of negative-pressure wound therapy may be considered. The patient is taken
back to the operating room for debridement of necrotic or nonviable tissue, wound irri-
gation, and repeat deep tissue cultures. The wound is closed over a Penrose or closed
suction drain.
Puncture Wounds of the Foot 321
The foot is evaluated the next day and the drain is removed once the wound site has
stopped draining. Antibiotic therapy is based on the final culture results. If the bone
cultures are positive, the patient should receive 6 weeks of intravenous antibiotics
followed by 4 weeks of oral antibiotics. If the infection only involves the soft tissue,
the patient should receive 2 weeks of intravenous antibiotics followed by 2 weeks of
oral antibiotics. Inflammatory markers, including the erythrocyte sedimentation rate
and C-reactive protein, should be evaluated every few weeks to evaluate the thera-
peutic process. The patient should be non–weight bearing with a protective cast
boot for 2 to 3 weeks until the sutures are removed, and then allowed to bear weight
as tolerated in the cast boot until such time that full weight bearing can resume. Phys-
iotherapy or occupational rehabilitation may be initiated to regain strength lost during
the period of treatment and recovery from the wound.
SUMMARY
Puncture wounds often appear benign but can go on to cause significant pedal
morbidity. Podiatric physicians who treat such wounds should educate local emer-
gency room, urgent care center, and primary care physicians as to the potential
complications associated with puncture wounds. Timely referral, recognition of the
potential complications, and appropriate treatment ensure that the wound does not
advance beyond a puncture wound. If complications have developed, aggressive
treatment is required to eradicate the infection and prevent pedal amputation.
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