Plantar puncture wounds are frequently encountered in the Emergency Department (ED).1 They account for approximately 7% of patients presenting to the ED with lower extremity trauma.2 Wounds are more likely to occur in the warmer summer months from May through October when people spend more time outdoors and barefoot. Nails produce the majority of puncture wounds followed less commonly by wood, glass, and other metal objects.2-5 Patients seek medical treatment following puncture wounds for many reasons including tetanus immunization, pain relief, retained foreign bodies, and treatment of established infections.
There are very little data regarding the proper management of plantar puncture wounds but it is clear that complications can and do arise.1-17 Infection and retained foreign bodies remain the most serious of these complications. The true risk of infection and osteomyelitis remains unknown. Rates of infection are estimated to be in the range of 6% to 11%, with only a fraction of these complications proceeding to osteomyelitis.2,4 Risk factors for the development of infectious complications have been identified and include puncture wounds to the forefoot, punctures through rubber-soled shoes, deep penetration, and diabetics (particularly those with neuropathy).6,7
One of the difficulties in reporting the incidence of plantar puncture wounds is that patients do not always present to the Emergency Department. Most patients remove the offending foreign body and never seek medical treatment. They present to the ED when there is a suspicion of a retained foreign body or an infection.8 Despite the high frequency with which Emergency Physicians are faced with patients who have sustained a plantar puncture wound, there is no standard of care for treating these injuries. The pathophysiology and management of plantar puncture wounds are dependent on a host of factors including the location of the wound, the penetrating material, the depth of penetration, the footwear at the time of injury, the time to presentation, and any concomitant illnesses. This chapter summarizes the approach to the management of the plantar puncture wounds.
ANATOMY AND PATHOPHYSIOLOGY
The foot is a complex structure (Figures 219-1 and 219-2). The plantar surface is composed of the skin and a thin subcutaneous layer. The skin has a thickened stratum corneum layer making it one of the thickest areas of epidermis in the body. This thickened epidermal layer gives the plantar surface protection against mechanical forces. The plantar aponeurosis extends over the base of the foot and forms the plantar fascia. Deep to the fascia are various muscles and tendons with their sheaths. The longitudinal arch of the foot extends from the metatarsal heads to the calcaneus. The dorsal surface of the foot has a thin skin layer without much subcutaneous tissue. Under the thin subcutaneous layer is the superior dorsal fascia and the dorsal aponeurotic layer which encompasses the extensor tendon sheaths.