Complications from Stepping on a Nail
Stepping on a nail can result in serious infections including osteomyelitis (bone infection), septic arthritis (joint infection), soft tissue abscess, and in diabetic patients, a 46-fold increased risk of amputation if the wound becomes infected. 1
Immediate Life-Threatening Complications
Infection Risk
- Puncture wounds are among the most commonly reported origins of external trauma leading to foot ulcers, particularly in the home environment. 1
- The infection rate following nail puncture wounds ranges from 6-15% in the general population, with significantly higher rates when treatment is delayed. 2, 3
- Pseudomonas aeruginosa is the predominant pathogen, isolated in 50-75% of infected nail puncture wounds, especially when the injury occurs through rubber-soled shoes (tennis shoes). 2, 4, 5
- Staphylococcus aureus is co-isolated with Pseudomonas in approximately 23% of cases. 4
Deep Structure Involvement
- Osteochondritis (bone and cartilage infection) develops in up to 94% of hospitalized patients with nail puncture wounds, particularly when the forefoot (zone 1—the area beneath the metatarsal heads) is penetrated. 5
- Septic arthritis occurs in approximately 18% of complicated nail puncture cases. 4
- Foreign body retention (shoe material, sock fibers, nail fragments) is found in 25% of patients requiring surgical intervention. 3
High-Risk Patient Populations
Diabetic Patients
- Diabetic patients face catastrophic outcomes: the risk of amputation increases 46-fold when a puncture wound becomes infected compared to non-diabetics. 1
- Diabetics with infected puncture wounds are five times more likely to require multiple surgical operations. 1
- Amputation risk is highest when patients do not feel the puncture at the time of injury due to peripheral neuropathy. 1
- Mortality rates in diabetic patients with trauma-related foot ulcers range from 3% to 40.4% across studies. 1
Immunocompromised Patients
- Patients with HIV, advanced liver disease, or asplenia have increased susceptibility to severe infection and systemic complications. 6
Specific Complications by Anatomic Location
Forefoot (Zone 1) Injuries
- 97% of hospitalized patients with deep puncture wounds had injuries in zone 1 (plantar surface beneath the metatarsal heads). 5
- This zone has the highest risk for osteochondritis and septic arthritis due to proximity to bone and joint structures. 5
Hand Puncture Wounds (for comparison)
- Hand puncture wounds carry the highest infection risk of any anatomic location and always warrant prophylactic antibiotics. 6, 7
- Complications include septic arthritis, osteomyelitis, and tenosynovitis. 6, 7
Delayed Presentation Complications
Time-Dependent Outcomes
- Delayed presentation is the single most important predictor of poor outcome. Patients with treatment failure had a median delay of 10 days versus 2 days for successfully treated patients. 3
- The operated group (requiring surgical debridement) had significantly longer time from injury to admission (5.0 ± 6.8 days) compared to the conservatively managed group (2.7 ± 3.8 days). 3
- Complications are more frequent when ulcers are left untreated or treatment is delayed. 1
Chronic Infections
- Nontuberculous mycobacterial infections can present weeks to months after puncture wounds contaminated with soil, causing chronic granulomatous tenosynovitis, bursitis, and osteomyelitis. 7
Systemic Complications
Fever and Sepsis
- Fever is present in approximately 60% of patients with complicated nail puncture infections. 8
- Systemic repercussion (sepsis) is uncommon but can occur, particularly in immunocompromised patients. 2
Laboratory Abnormalities
- Elevated erythrocyte sedimentation rate occurs in 80% of infected cases. 8
- Leukocytosis is present in only 40% of cases, making it an unreliable marker. 8
- White blood cell count, ESR, and fever are NOT significantly associated with treatment outcome or success. 3
Specific Complications Requiring Prolonged Treatment
Osteomyelitis
- Requires 4-6 weeks of targeted antibiotic therapy. 6, 7, 9
- Relapse rate is approximately 2.6% with appropriate surgical debridement and antibiotics. 4
Septic Arthritis
- Requires 3-4 weeks of targeted antibiotic therapy. 6, 7, 9
- Two relapses in one series occurred in patients with previously undetected septic arthritis. 4
Soft Tissue Abscess
- Deep tissue abscess formation occurs in all patients who develop clinically significant infection. 8
- Requires surgical drainage in addition to antibiotics. 8
Factors That Worsen Outcomes
Footwear-Related Risk
- Tennis shoes (rubber-soled footwear) predispose to Pseudomonas aeruginosa infection by introducing shoe material and creating an anaerobic environment. 5
- Wearing tennis shoes was documented in 91% of pediatric osteochondritis cases. 4
Pre-Hospital Antibiotic Use
- Patients who received antibiotics in the community before hospitalization were more likely to have treatment failure (100% versus 47.2%). 3
- This likely reflects selection bias (sicker patients received antibiotics) but may also indicate inadequate antibiotic coverage for Pseudomonas. 3
Critical Pitfalls Leading to Complications
Inadequate Initial Management
- Failure to perform copious irrigation with running tap water or sterile saline until no visible debris remains. 6
- Attempting primary wound closure, which markedly increases infection risk. 6, 7
- Using inadequate antibiotic coverage (first-generation cephalosporins, macrolides, or clindamycin alone lack Pseudomonas coverage). 6, 7
Missed Foreign Bodies
- Plain radiographs miss radiolucent materials (wood, plastic, rubber) in 100% of cases. 7
- Ultrasonography is useful for detecting foreign bodies and should be employed when clinical suspicion persists. 3