Browse categories and answer follow-up questions to refine your symptom profile.
History
Mechanism and context
Mechanism and context
Object type
Metal
Glass
Wood
Plastic
Fish hook
Nail
Needle
Environment
Soil
Farm
Water exposure
Shoe puncture
Timing
Time since injury
Immediate symptoms at time of injury
Self removal attempts
Attempted extraction
Irrigation at home
Symptoms and functional impact
Symptoms and functional impact
Pain
Rest pain
Pain with motion
Pain with weight bearing
Swelling
Progressive swelling
Localized swelling
Drainage
Purulent
Serous
Function
Reduced range of motion
Reduced grip or pinch
Limp
OPQRST
OPQRST
Onset
Sudden at time of puncture
Delayed worsening after initial improvement
Provocation and palliation
Worse with movement
Worse with weight bearing
Relief with elevation
Relief with immobilization
Quality
Sharp
Throbbing
Burning
Region and radiation
Localized to wound
Proximal spread along tendon sheath path
Severity
Mild
Moderate
Severe
Timing
Constant
Intermittent
Worsening over hours
Worsening over days
Associated symptoms
Associated symptoms
Infection symptoms
Fever
Chills
Malaise
Neurovascular symptoms
Numbness
Tingling
Coolness
Musculoskeletal symptoms
Mechanical locking
Loss of active extension or flexion
Prior episodes and baseline
Prior episodes and baseline
Prior similar wounds
Prior retained foreign body
Prior deep infection
Baseline function
Baseline gait
Baseline hand function
Alarm Features
Immediate escalation triggers
Immediate escalation triggers
Hemodynamic instability
Hypotension
Tachycardia with poor perfusion
Rapidly progressive soft tissue infection
Pain out of proportion
Rapidly expanding erythema
Bullae
Skin necrosis
Neurovascular compromise
Absent distal pulses
Progressive sensory loss
Compartment syndrome concern
Pain with passive stretch
Tense compartments
High risk wound features
High risk wound features
Deep penetration
Through shoe
Into tendon sheath region
Near joint
Retained foreign body concern
Foreign body sensation
Incomplete object after removal
Contamination burden
Soil contamination
Organic material
System red flags
System red flags
Sepsis physiology
Fever with tachycardia
Altered mental status
Necrotizing infection physiology
Severe pain
Systemic toxicity
Medications
Home meds and interactions
Home meds and interactions
Anticoagulants and antiplatelets
Warfarin
DOAC
Clopidogrel
Immunosuppressants
Chronic steroids
Biologics
Diabetes meds
Insulin
SGLT2 inhibitor
Analgesics and antibiotics exposure
Analgesics and antibiotics exposure
Pre ED analgesics
Acetaminophen
NSAID
Recent antibiotics
Beta lactam
TMP SMX
Fluoroquinolone
Vaccine and immune products
Vaccine and immune products
Tetanus immunization history
Last tetanus containing vaccine date
Primary series complete status
Immune globulin exposure
Prior TIG
Allergy history to immune products
Diet
Intake and exposure context
Intake and exposure context
Hydration
Poor intake from pain or illness
Vomiting limiting oral intake
Alcohol exposure
Intoxication at time of injury
Withdrawal risk
Food and water exposure related to wound
Freshwater exposure
Saltwater exposure
Review of Systems
Constitutional and infection
Constitutional and infection
Fever
Documented
Subjective
Chills
Rigors
Mild chills
Malaise
Fatigue
Myalgias
Skin and musculoskeletal
Skin and musculoskeletal
Local skin change
Erythema
Warmth
Lymphangitic streaking
Joint symptoms
Pain with range of motion
Swelling
Tendon symptoms
Triggering
Loss of active motion
Neurovascular
Neurovascular
Sensory
Numbness
Paresthesia
Motor
Weakness
Loss of function
Perfusion
Cool extremity
Color change
Collateral History and Family History
Collateral and circumstances
Collateral and circumstances
Witness report
Mechanism confirmation
Object identification
Caregiver reliability
Ability to monitor
Ability to return for reassessment
Family history relevant to complications
Family history relevant to complications
Bleeding disorders
Hemophilia
von Willebrand disease
Immune disorders
Primary immunodeficiency
Neutropenia syndromes
Risk Factors
Infection risk
Infection risk
Diabetes mellitus
Poor control history
Neuropathy
Immunocompromise
HIV
Chemotherapy
Transplant
Peripheral vascular disease
Claudication
Prior ulcers
Foreign body and deep structure risk
Foreign body and deep structure risk
Location risk
Hand
Foot plantar
Face
Depth risk
Near joint capsule
Near tendon sheath
Material risk
Wood radiolucent risk
Organic material inflammatory risk
Special populations
Special populations
Pregnancy
Imaging radiation minimization
Antibiotic selection constraints
Pediatrics
Weight based dosing
Sedation needs for exploration
Differential Diagnosis
Life threatening
Life threatening
Necrotizing soft tissue infection (M72.6)
Pain out of proportion
Systemic toxicity
Compartment syndrome
Pain with passive stretch
Progressive neurologic deficit
Septic arthritis (M00.9)
Pain with passive range of motion
Effusion
Flexor tenosynovitis of hand
Fusiform swelling
Pain with passive extension
Vascular injury
Pulsatile bleeding history
Distal ischemia
Common
Common
Retained foreign body
Foreign body sensation
Persistent focal tenderness
Cellulitis (L03.90)
Expanding erythema
Warmth and tenderness
Local abscess (L02.91)
Fluctuance
Purulent drainage
Traumatic bursitis
Local swelling
Pain with pressure
Less common
Less common
Osteomyelitis (M86.9)
Persistent pain beyond expected
Risk increased in diabetes and deep puncture
Gas forming infection
Crepitus
Soft tissue gas on imaging
Allergic or foreign body granuloma
Subacute nodule
Chronic draining sinus
Mimics and pitfalls
Mimics and pitfalls
Simple post traumatic inflammation
Improves within 24 to 48 hours
No progressive erythema
Referred pain
Proximal tendon injury
Radiculopathy unrelated
Underestimated depth
Small skin entry with deep track
Missed joint violation
Past Medical History
Relevant conditions
Relevant conditions
Diabetes mellitus (E11.9)
Neuropathy history
Prior foot infections
Peripheral arterial disease (I73.9)
Prior revascularization
Prior ulcers
Immunosuppression
Chronic steroid use
Biologic therapy
Chronic kidney disease (N18.9)
Antibiotic dosing implications
Imaging contrast risk
Prior procedures and devices
Prior procedures and devices
Orthopedic hardware near region
Joint replacement
Plates and screws
Prior tendon repair
Reduced baseline range
Higher injury risk
Physical Exam
General and vital signs
General and vital signs
Appearance
Toxic
Non toxic
Vital sign patterns
Fever
Tachycardia
Hypotension
Wound and local soft tissue
Wound and local soft tissue
Entry site
Location mapping
Size of puncture
Track and depth clues
Visible track
Subcutaneous emphysema
Infection signs
Erythema margins
Warmth
Induration
Drainage
Foreign body clues
Focal point tenderness
Palpable object
Neurovascular
Neurovascular
Perfusion
Capillary refill
Skin temperature
Pulses
Distal palpable pulses
Doppler signals if weak
Sensation
Light touch
Two point discrimination for digits
Motor
Tendon specific active motion
Intrinsic hand function
Musculoskeletal and special region exam
Musculoskeletal and special region exam
Range of motion
Active
Passive
Joint involvement clues
Effusion
Pain with passive range of motion
Tendon sheath involvement clues
Fusiform swelling
Pain along sheath
Compartment syndrome screening
Pain out of proportion
Pain with passive stretch
Lab Studies
Infection and inflammation labs
Infection and inflammation labs
CBC
Leukocytosis interpretation limited in early infection
Neutropenia increases risk for severe infection
CRP
Trending for deep infection suspicion
May be normal early
ESR
Osteomyelitis support when elevated
Low specificity
Sepsis and metabolic labs
Sepsis and metabolic labs
Lactate
Elevated supports hypoperfusion
Normal does not exclude serious infection
BMP
Renal function for antibiotic dosing
Electrolytes for systemic illness
Glucose
Hyperglycemia worsens infection risk
Hypoglycemia in severe illness
Microbiology
Microbiology
Blood cultures
Systemic toxicity
Immunocompromised
Wound culture
Purulent drainage
Prior antibiotics or failure of initial therapy
Imaging
Scoring Systems
Scoring Systems
LRINEC for necrotizing infection
Low sensitivity
Do not use to rule out
Ottawa ankle and foot rules for concomitant trauma
Use when injury mechanism suggests fracture
Not a retained foreign body tool
MRI
MRI
Indications
Osteomyelitis evaluation when X ray negative and suspicion persists
Deep space infection mapping
Contraindications and cautions
Metallic foreign body concern
Implanted device compatibility
CT
CT
Indications
Deep foreign body when ultrasound nondiagnostic
Deep space infection extent
Limitations
Low sensitivity reported for some foreign bodies
Radiation exposure
Ultrasound
Ultrasound
Indications
Radiolucent foreign body concern
Abscess versus cellulitis differentiation
Performance and pitfalls
Sensitivity reported 79 to 100 percent with experienced operators
Specificity reported 86 to 100 percent with experienced operators
Plain radiography
Plain radiography
Indications
Glass
Metal
Gravel
Limitations
Low sensitivity for wood and plastic
Limited soft tissue structure detail
Special Tests
Bedside procedures and diagnostics
Bedside procedures and diagnostics
Wound exploration under adequate anesthesia
Direct visualization preferred over blind probing
Stop if neurovascular or tendon injury concern
Saline load test for suspected joint violation
Local protocol dependent thresholds
Orthopedics input for technique and interpretation
Function tests for deep injury
Function tests for deep injury
Tendon function
Isolated flexor and extensor testing
Comparison to contralateral side
Nerve testing
Two point discrimination in digits
Motor branch testing for hand nerves
Compartment syndrome adjuncts
Compartment syndrome adjuncts
Compartment pressure measurement
Consider when exam equivocal and high suspicion
Serial measurements may be needed
Delta pressure concept
Local protocol dependent cutoff use
Clinical exam remains primary
ECG
When relevant
When relevant
Systemic toxicity
Tachyarrhythmia evaluation
Baseline QT before QT prolonging antibiotics
Significant comorbidity
Known coronary disease with chest symptoms
Electrolyte derangement concern
High risk findings
High risk findings
Sepsis related changes
Sinus tachycardia
New atrial fibrillation
Medication related changes
QT prolongation
Conduction delay
Assessment
Problem representation
Problem representation
Puncture wound with retained foreign body concern
Location and depth risk summary
Material type suspicion
Puncture wound with infection concern
Cellulitis features present or absent
Abscess features present or absent
Severity and risk stratification
Severity and risk stratification
Low risk
Superficial wound
No systemic symptoms
Moderate risk
Hand or foot involvement
Comorbidity such as diabetes
High risk
Deep structure concern
Systemic toxicity
Complications to rule out
Complications to rule out
Joint violation
Pain with passive range of motion
Wound near joint line
Tendon sheath infection
Fusiform swelling
Pain with passive extension
Osteomyelitis
Persistent pain
Delayed presentation
Necrotizing infection
Pain out of proportion
Skin necrosis or bullae
Plan
Approach to critical patient first 5 minutes
Approach to critical patient first 5 minutes
Monitoring
Cardiac monitor if systemic toxicity
Continuous pulse oximetry if ill appearing
IV access
Two large bore IV if sepsis concern
Single IV if moderate infection risk
Early antibiotics timing
Within 1 hour if septic shock physiology
After cultures if stable and cultures indicated
Analgesia and local anesthesia
Analgesia and local anesthesia
Oral analgesia
Acetaminophen 1000 mg PO once then every 6 to 8 hours as needed
Ibuprofen 400 mg PO once then every 6 to 8 hours as needed
Local anesthesia options
Lidocaine 1 percent local infiltration
Regional block for digits when appropriate
Wound care and foreign body management
Wound care and foreign body management
Irrigation principles
Copious irrigation with sterile saline
Avoid high pressure irrigation in small punctures if tissue dissection risk
Exploration strategy
Imaging guided localization if not visualized
Avoid blind deep probing near neurovascular bundles
Foreign body removal
Superficial visible object removal
Surgical consult for deep or high risk location removal
Antibiotics and prophylaxis
Antibiotics and prophylaxis
No routine prophylaxis for uncomplicated clean superficial puncture
Shared decision if high risk host
Close follow up plan required
Prophylaxis or treatment indications
Gross contamination
Delayed presentation
Hand or foot puncture
Diabetes or immunocompromise
Adult oral options for non bite puncture cellulitis coverage
Cephalexin 500 mg PO every 6 hours
Clindamycin 300 mg PO every 6 to 8 hours for beta lactam allergy
MRSA risk options local protocol dependent
TMP SMX one double strength tablet PO every 12 hours plus beta lactam for streptococci
Doxycycline 100 mg PO every 12 hours plus beta lactam for streptococci
Plantar puncture through shoe pseudomonas risk local protocol dependent
Ciprofloxacin 500 mg PO every 12 hours adult only
Orthopedics and infectious diseases input if bone or joint involvement concern
Bite related puncture coverage
Amoxicillin clavulanate 875 mg PO every 12 hours adult
Alternative regimen local protocol dependent if penicillin allergy
Tetanus prophylaxis
Tetanus prophylaxis
Tetanus prone wound category
Puncture wound considered tetanus prone
Contaminated wound increases risk
Vaccine logic
If unknown or incomplete primary series then tetanus vaccine plus TIG
If completed primary series then booster timing based on wound type and time since last dose
TIG dosing examples
Adults and age 7 and older 250 units IM
Local protocol dependent product availability
Reassessment loop
Reassessment loop
Timing
Recheck pain and neurovascular status after anesthesia and procedures
Repeat exam within 30 to 60 minutes if concern for progression
Triggers
Increasing pain
New numbness
Expanding erythema
Disposition
Admission and higher level of care criteria
Admission and higher level of care criteria
ICU or resuscitation level
Septic shock physiology
Necrotizing infection concern
Inpatient admission
Deep space infection
Suspected septic arthritis
Suspected osteomyelitis
Uncontrolled pain requiring IV opioids
Observation pathway
Moderate cellulitis needing IV antibiotics
Need for serial neurovascular exams
Discharge criteria
Discharge criteria
Clinical stability
Normal or improving vital signs
No systemic toxicity
Local exam stability
No rapidly progressive erythema
Neurovascularly intact
Plan reliability
Follow up within 24 to 72 hours
Return precautions understood
Follow up timing
Follow up timing
Wound check
24 to 48 hours for high risk wounds
48 to 72 hours for low risk wounds
Specialty follow up
Hand surgery for hand punctures with deep concern
Orthopedics for plantar puncture with bone or joint concern
Discharge Instructions
Copy discharge instructions
Copy discharge instructions
Today you were seen for a puncture wound
We checked for signs of infection and deep injury
A foreign body may not always be visible at first visit
Wound care
Keep the area clean and dry for the first day
Then wash gently with soap and water daily
Do not soak in a bath or hot tub until healing
Pain control
Acetaminophen as directed on the label
Ibuprofen as directed on the label if safe for you
Antibiotics
Take exactly as prescribed until finished
Return if you cannot keep medicines down
Activity
Limit use of the injured area for 24 to 48 hours
Elevate when resting to reduce swelling
Return to the emergency department now for
Fever
Rapidly worsening redness or swelling
Pus or bad smelling drainage
Increasing pain especially pain with stretching the area
Numbness or weakness
Fingers or toes becoming cold or pale
Follow up
See your clinician for a wound check within the recommended timeframe
If you were told there may be a retained foreign body, follow up even if symptoms improve
References
Guidelines and key evidence
Guidelines and key evidence
CDC Clinical Guidance for Wound Management to Prevent Tetanus 2025
Tetanus vaccination and TIG based on wound type and immunization history
Antibiotics not recommended solely to prevent tetanus
Public Health Agency of Canada Canadian Immunization Guide Tetanus toxoid and TIg dosing
TIg adult dose example 250 units IM
Local protocol dependent
Infectious Diseases Society of America Practice Guidelines for Skin and Soft Tissue Infections 2014 update
Classification and management framework for cellulitis and abscess
Severity based disposition considerations
American College of Emergency Physicians Sonoguide Foreign Body Localization 2020
Ultrasound useful for radiolucent foreign bodies
Reported sensitivity 79 to 100 percent and specificity 86 to 100 percent in experienced hands
NICE Guideline NG184 Human and animal bites antimicrobial prescribing 2020
Antibiotic indications for infected bite wounds
Risk factor based prophylaxis concepts
Manthey et al Annals of Emergency Medicine Ultrasound versus radiography for soft tissue foreign bodies 1996
Radiography high sensitivity for radiopaque foreign bodies
Radiography poor detection of radiolucent foreign bodies
SymptomDx is an educational tool for medical professionals. It does not replace clinical judgment. Verify all clinical data and drug dosages with authoritative sources.