Emergent Care / Stabilization
It is important to initially assess the extent of the injury with special attention to whether the foot is neurovascularly intact. Analgesics can be used as needed before moving on to imaging and management.

Causes / typical injury mechanism: Foot puncture wounds are an acute injury. They typically occur at the plantar foot by stepping onto foreign objects. The setting of this injury can vary from the backyard to an occupational worksite and is often associated with inadequate footwear.

Classic history and presentation: Foot puncture wounds most commonly occur following trauma to the foot. The location and depth of the injury can vary significantly. There will likely be associated pain, bruising, and swelling within the first 24 hours. Foreign bodies may or may not be retained upon presentation. Nails are the most common foreign body in puncture wounds. Other common objects include needles, glass, wood, plastic, and metal. An object puncturing through a rubber-soled shoe or sneaker and into the foot increases the risk of infection with Pseudomonas aeruginosa. These patients may be at a higher risk of developing osteomyelitis. 

It is possible this injury will have associated bone fracture, ligament and tendon injury, soft tissue damage, or neurovascular compromise. Many patients may delay medical care until 1 or more of these complications have developed. It is also well-documented that patients with diabetes mellitus (type 1, type 2) develop more complications from foot puncture wounds.

Prevalence: Common in summer and fall months.

• Age – All ages are affected, including children.
• Sex / gender – There is no sex or gender predilection.

Risk factors: Risk factors for injury include acute trauma, inadequate footwear, and neuropathy. Risk factors for further complications are diabetes mellitis, immunocompromised status, and puncture wounds located at zones 1 and 3 (see Grade / classification system).

Pathophysiology: Foot puncture wounds are caused by penetration of an object into the foot. Collateral bone, ligaments, tendons, vasculature, or nerves may be pierced as well.

Grade / classification system: There is a classification system developed by Patzakis and colleagues for locating the site of injury on the plantar aspect of the foot.

• Zone 1 – Distal phalanges to metatarsal necks
• Zone 2 – Metatarsal necks to the distal aspect of the calcaneus
• Zone 3 – Plantar aspect of the calcaneus