Obtain patient′s baseline functional and ambulatory status.

Determine medical comorbidities.

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  Vascular disease, smoking, nutritional status, immunosuppression, renal disease, autoimmune disease, radiation, coagulopathy.

Assess for evidence of impaired peripheral blood flow.

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  Palpation and Doppler examination of dorsalis pedis and posterior tibial arteries, check of capillary refill, pulse oximeter reading on each toe to assess viability, observation of bleeding wound edges.

Motor and sensory examination to assess extent of injury.

Tetanus status.

Redundancy to evaluate bony framework and possible foreign bodies (i.e., bullet fragments).

Consider angiography for possible vascular injury and preoperative surgical planning.

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  Magnetic resonance angiography and computed tomographic angiography are additional options when the patient is not a candidate for an invasive interventional procedure with contrast dye injection under general anesthesia.

  
  
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  Renal status may be pertinent to deciding the appropriate modality.

Trauma evaluation.

Orthopedic surgery, for management of bony injury.

Vascular surgery, if vascular inflow is a concern.

Thorough operative irrigation and débridement performed emergently

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  All nonviable tissue needs to be removed and sharply débrided.

  
  
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  Copious irrigation and removal of foreign bodies.

  
  
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  Careful examination of the extent of the wound (under tourniquet).

  
  
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  Consider wound vacuum-assisted closure (VAC) placement between procedures.

  
  
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  Repeat wound exploration and débridement after 48 hours.

Preoperative antibiotics to reduce risk for wound infection.

Appropriate management of fractures as indicated.

Definitive closure only after wound is clean and bony stabilization is obtained

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  Stable biomechanical alignment is the first goal of acceptable foot function.