Chapter 163

Plantar puncture wounds are encountered quite frequently in the Emergency Department. They are often incurred while walking barefoot or in the course of work. Nails produce the majority of such wounds. Various other objects such as wood, metal, and glass are also common causes. There is very little data regarding the proper management of plantar puncture wounds, but it is clear that complications can and do arise.1–4 Infection and retained foreign bodies remain the most serious of these complications.

One of the difficulties with 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. The true risk of infection and osteomyelitis remains unknown. The infection rate is estimated to be approximately 2 to 8 percent, with only a fraction of these complications proceeding to osteomyelitis.1 There are seasonal variations, with the warm months, from May through October, being the peak times for plantar puncture wounds.1

The pathophysiology and management of plantar puncture wounds is 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 and management of the plantar puncture wound.

The foot is a complex structure (Figures 163-1 and 163-2). 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 and 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.

Figure 163-1

The anatomy of the foot in midsagittal section.

Figure 163-2

The anatomy of the foot. Cross-section just proximal to the metatarsal heads.

The thickened plantar epidermal layer prevents minor mechanical insults from penetrating the skin. An object can puncture the plantar surface of the foot and compromise the deeper layers of the foot. The impaling object may just breach the plantar fascia or even go through the foot, depending on the depth of penetration.

Determine if the penetrating object is small, such as a needle or pin, and if a portion may still be ...

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