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
The anatomy of the foot in midsagittal section.
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 ...