Summary Foot Puncture Wounds are common work place injuries which are at high risk for soft tissue infection and development of osteomyelitis. Diagnosis is clinical with inspection of the plantar foot for the puncture site as well as surrounding erythema and drainage. MRI studies are indicated when there is concern for osteomyelitis. Treatment can be observation with antibiotics or surgical debridement depending on chronicity of wound, patient comorbidities and presence of soft tissue infection or osteomyelitis. Epidemiology Incidence common injury in certain work-places (i.e. construction sites) approximately 10% develop infection approximately 1-2% develop osteomyelitis Etiology Pathophysiology mechanism of injury usually stepping on a nail or stick through a sock/sole of foot microbiology most common cause of soft tissue infection is Staph aureus most common cause of osteomyelitis is pseudomonas Presentation Presentation often present weeks to a month after initial injury limp Physical exam swollen and tender foot obvious wound, with or without tract well-demarcated erythema may present with lymphadenopathy Imaging Radiographs required views ap and lateral findings normal early bone destruction seen later exclude presence of foreign body MRI indications obtain prior to operative irrigation and debridement used to rule out osteomyelitis may occur in 1-2% Treatment Nonoperative tetanus booster, prophylactic antibiotics (controversial) indications recent (within hours) puncture wound with no evidence of infection if open wound, bedside irrigation and debridement no standard prophylactic abx for acute (within hours) injury, but should cover for Pseudomonas Operative surgical debridement indications late/delayed presentation with deep infection with/without osteomyelitis foreign body removal no improvement with PO antibiotics technique tract and soft tissue debridement deep culture bony curretage (if osteo) packing with wick to allow for healing by secondary intention postoperative follow with IV antibiotics (coverage for pseudomonas) convert to PO antibiotics once clinical picture improves antibiotic choice preferred antibiotics ciprofloxacin or levofloxacin (except in children) alternative antibiotics: ceftazidime or cefepime