What is the diagnosis?

Puncture wound of the foot. 

What is the important finding in this image and how does that change the management in the ED?

The shoe! Since this puncture wound occurred through a rubber-soled shoe, the patient needs to have antibiotics for Pseudomonas coverage [1]. Moist conditions, such as in an athletic or work shoe, increase the risk of Pseudomonas development. You should consider coverage for Staphylococcus infection as well with cephalosporin (Keflex). 

• Pearl: Appropriate prophylaxis is with ciprofloxacin.  The other oral fluoroquinolones do not have as good of tissue penetration [2]. 

Patient should have the foreign body removed. The wounds should be washed out thoroughly while in the ED. Tetanus vaccine should be updated if needed. Puncture wounds should not be closed to help prevent infection. 

• Pearl: If the patient had this exposure in water, you should consider additional coverage: 

• Doxycycline 100 mg BID - Sea water exposure (Vibrio prophylaxis) [3]

When do you consult Orthopaedics?

For the most part these can be treated conservatively and do not need to have Orthopedic involvement. However, there are a few presentations that could require surgical intervention [4]: 

• Retained foreign body

• Ultrasound can be helpful here if foreign body is not radiopaque

• Deep wound that involves the bony structures

• Delayed presentation and obvious infection present already