Puncture wounds of the foot: stepping on a nail

Why a small puncture can turn serious

A nail, tack, sliver of glass or splinter pierces the sole. The surface hole is small, so a foot puncture wound can look minor even when it went deep.⁠^[4]

When infection does set in, it can stay in the skin and soft tissue or travel into a joint, its cartilage or the bone (osteomyelitis).⁠^[3,5]

Tetanus: check when you had your last shot

The Centers for Disease Control and Prevention (CDC) lists puncture wounds among “dirty or major” wounds. If you completed the first series of tetanus shots, you need a booster when your last dose was five or more years ago. If you never had the shots, didn’t finish the series or don’t know, you should be vaccinated now and also receive tetanus immune globulin, an injection of ready-made antibodies. The immune globulin is also advised for people with HIV or a severely weakened immune system.⁠^[2]

We ask when you had your last tetanus shot and tell you whether you need one. If you do, don’t put it off: your primary care doctor, an urgent care center or the emergency department can give it.

Sneakers, rubber soles and the germs involved

In a 10-year series of 77 children with Pseudomonas infection of the cartilage, bone or joint after a nail puncture, 70 had been wearing tennis shoes.⁠^[3] In one hospital study of adults, Pseudomonas was the most common cause of bone infection after a puncture in those without diabetes; in those with diabetes, Staphylococcus aureus and infections with several germs at once were more common.⁠^[5]

A nail through a rubber sole can also leave tiny pieces behind: at one hospital where surgeons explored 125 deep punctures of this kind, pieces 1–4 mm across were removed in 37 people, about 30%.⁠^[4]

Because the germ decides the antibiotic, we culture a sample of infected tissue when we can, rather than relying on a surface swab.⁠^[7]

Signs of infection after a puncture

Call us if, in the days or weeks after the injury, you notice:

• pain or tenderness that gets worse instead of better
• redness, warmth or swelling around the hole
• pus or other drainage⁠^[7,8]

If you have diabetes, numb feet or poor circulation, call the same day; evenings and weekends, go to urgent care or the emergency department.

Fever or chills, or redness that is spreading, can mean a more serious infection.⁠^[7] Don’t wait for an office visit if you have any of these, foul-smelling drainage or you feel very unwell: go to the emergency department or call 911.

Signs can be quiet. Among adults admitted with infected punctures, pain was the main complaint in 93% of those without diabetes but only 70% of those with it, and more than half had a normal white blood cell count despite needing urgent drainage.⁠^[8]

Delay may matter: among 96 adults whose nail went through a rubber-soled shoe, the few with a poorer result had waited a median of 10 days before admission, compared with 2 days for the rest.⁠^[9] If a puncture that seemed fine starts to hurt again, have it checked; see also a red, hot, swollen foot.

Puncture wounds when you have diabetes

Diabetic nerve damage can take away feeling in the feet, so you may not feel a small injury.⁠^[10] (The Nerve Institute explains peripheral neuropathy (external site).) In one hospital study, people with diabetes were more often numb and barefoot when injured, and reached treatment later.⁠^[5]

Among 114 people already in the hospital with an infected puncture, those with diabetes more often had a bone infection (37% compared with 7%), needed surgery (95% compared with 77%) and needed an amputation of some kind (48% compared with 7%).⁠^[6] That is why we would rather see a puncture early, before infection takes hold. International guidelines list a puncture wound, or an object left in the foot, among the features of a more serious diabetic foot infection.⁠^[7]

How a puncture wound is evaluated

We ask what you stepped on, what you wore and whether the object came out whole, then examine the wound, test the feeling in your foot and check your circulation, with noninvasive testing at our practice when needed.

X-ray and ultrasound are both available at our practice. Ultrasound can help find a piece of the object left in the foot,⁠^[9] but small pieces are easy to miss, so a normal scan doesn’t rule one out or settle whether you need surgery.⁠^[4] For people with diabetes, guidelines suggest plain X-rays as one of the first tests when bone infection is a concern.⁠^[7]

When bone infection is still in doubt after the exam, X-rays and blood tests, the same guidelines recommend an MRI;⁠^[7] we arrange it at an outside imaging center. See how a foot wound is evaluated.

Caring for a fresh puncture

Many punctures need only careful wound care. Even in the 96-adult study above, 36 were treated without an operation.⁠^[9]

We clean the wound, look for anything left inside and see you again to make sure it is healing (see wound care visits). For a fresh puncture that isn’t infected, we decide with you whether antibiotics make sense, weighing how deep it went, what went in, your footwear and your health.

When surgery is the right step

When infection reaches deep tissue, a joint or bone, surgery is often what turns it around. The operation opens and cleans the wound track, drains pus, removes dead or infected tissue and sends tissue for culture.⁠^[7,3] Any fragment of the object or shoe rubber comes out at the same time.⁠^[9]

Thorough surgery can work well. In the 77 children, every child had surgery to clean out infected cartilage or bone, after which about a week of antibiotics was enough.⁠^[3] In the 96 adults, most of whom had an operation, treatment succeeded in about 95%.⁠^[9]

For moderate or severe diabetic foot infections, guidelines suggest considering surgery within 24–48 hours, together with antibiotics, to remove infected and dead tissue. When bone is infected, they suggest considering removing it.⁠^[7]

Dr. Ozturk, a Foot and Ankle Surgeon who is also board certified in wound care (FAPWH), performs this surgery, including removing infected bone when needed. See surgery for diabetic foot infection and bone infection (osteomyelitis).

Recovery and what to expect

After surgery, we see you for wound care until the wound closes, using dressings and, for the wounds that need it, negative-pressure wound therapy (a wound VAC).

Removing infected bone can shorten your antibiotics: when all of it is removed, guidelines for people with diabetes suggest 2–5 days of antibiotics afterward, compared with 6 weeks when bone infection is treated without surgery.⁠^[7]

Surgery has limits. More than one operation may be needed: in the study of 114 people, those with diabetes averaged 2.7 operations, compared with 1.3 without diabetes.⁠^[6] Infection can also come back if part of it is missed: two of the 77 children relapsed, both with a joint infection that hadn’t been found.⁠^[3] If you have been told you need an amputation, a second opinion can help you weigh your options.

Preventing puncture wounds

With diabetes or numb feet, wear shoes and socks at all times, never walk barefoot or in just socks (even indoors), and check inside your shoes before putting them on. Checking your feet each day helps you spot problems early.⁠^[10] Our main practice has a guide to the daily foot check (external site).

When to seek care

See us within a day or two for any foot wound that isn’t healing, especially if you have diabetes. With diabetes or numb feet, that includes any puncture, even a small one that doesn’t hurt. Our offices in Lyndhurst, Paramus and Millburn all provide wound care: call 908-215-5953 or book through Zocdoc.