Foreign Body Removal

Published on 08/04/2015 by admin

Filed under Emergency Medicine

Last modified 22/04/2025

Print this page

This article have been viewed 12228 times

Chapter 36

Foreign Body Removal

Daniel B. Stone and David J. Scordino

Evaluation and Diagnosis

A foreign body (FB) is any substance that is not naturally part of the body. These cases are common in the clinical setting. An FB should be suspected whenever the skin is broken. A thorough history and physical examination are essential to assess the risk for an FB. During assessment, remember that FBs may not be obvious and that the wound may appear closed, but they should be considered whenever the history is particularly concerning. For example, a patient who is walking without shoes and experiences a sharp, sudden pain in the foot may have a needle, toothpick, or any other similar type of FB, even when a “sprained foot” seems obvious (Fig. 36-1). Certain mechanisms of injury, such as punching or kicking out a window or stepping on an unknown object while walking in a field or stream, are associated with a retained FB. Mechanisms that make FBs less likely include lacerations from metal objects; however, if considerable force was applied during the injury and the object is not available for inspection, radiographic imaging may be warranted since bone may have been encountered and a small section might have splintered off the offending object. The history should also include asking whether the patient perceives or suspects an FB. Steele and associates found that the negative predictive value of patient perception was 89% but that the positive predictive value was just 31%.¹ Importantly, the patient’s past medical history should be explored for allergies to local anesthetics, bleeding diatheses, diabetes mellitus, vascular disease, uremia, immunocompromised state, or other diseases that would affect wound healing or management.

Figure 36-1 A, A common foreign body (FB) in the foot is a splinter, toothpick, pin, or needle that is impaled while walking barefoot on a carpet. This sewing needle (arrow) was obvious, but in the absence of a history of an FB, some FBs may be mistaken for a simple puncture wound, heel spur, stress fracture, contusion, or tendinitis. B, A commonly missed FB is the second one. Postoperative radiographs demonstrate complete removal. C, This patient fell, landed on a metal pipe, and suffered a deep laceration in the thigh. A radiograph was taken to rule out a fracture, and the key was seen but thought to be an artifact (i.e., an item left on the backboard). During the examination the key was found embedded in the wound. It had been in the patient’s pants pocket and was forced into the wound by the pipe during the injury.

Before the physical examination be sure to have enough examination time, as well as proper space and equipment. It is important to confirm that the patient is willing to undergo the procedure because cooperation is essential to optimize success. Attempts at removing an FB in an overtly uncooperative patient, such as one who is intoxicated, drugged, cognitively limited, or confused, is potentially injurious to both the examiner and the patient. In most noncritical situations, if a patient is uncooperative, perform the examination again when the patient is able to cooperate. In benign cases, follow-up can occur a few days later.

During the physical examination, carefully palpate the periphery of all wounds to elicit tenderness because retained FBs often produce pain. Also, some FBs can migrate away from the wound or perceived entry point. Some superficial FBs may be palpated through the skin, but surprisingly large FBs may be found in seemingly minor wounds without much external evidence. In some cases, the external characteristics of the wound do not yield firm evidence regarding the presence or absence of an FB. Deeper FBs may not be palpable and must be localized by other techniques.

Exploration is an important part of the bedside evaluation, whether done initially or after further imaging studies (Fig. 36-2). This requires adequate pain control, good lighting, proper equipment, a bloodless field, a cooperative patient, and appropriate positioning to visualize as much of the wound as possible (Figs. 36-3 and 36-4). A metal probe may help identify the FB by feel or sound. Glass, as an example, is difficult to identify by sight in soft tissue, but touching it with metal causes a characteristic grating sound. Probing a wound with a gloved finger to locate or identify an FB is strongly discouraged because of the risk of the FB penetrating the glove and exposing the clinician to human immunodeficiency virus (HIV) and hepatitis (Fig. 36-5). Alternatively, some authors have suggested injecting the entrance wound with methylene blue to outline the track of the FB.² The blue line of injected dye is followed into the deeper tissues. This technique is of limited value because the track of the FB often closes tightly and does not allow passage of the methylene blue.

Figure 36-2 Some wound mechanisms are classic for the presence of a foreign body (FB). A, This intoxicated patient kicked out a window and sustained seemingly minor puncture wounds. He did not believe that glass was in the wound, there was little pain, and no FB could be palpated externally. B, A radiograph revealed a large shard of glass (arrows) deeply embedded in the wound. C, The shard of glass was removed, but only after 20 minutes of exploration. D, Another classic scenario for a retained glass FB is putting the arm through a window. An FB was not suspected or sensed by the patient or clinician. E, When a radiograph was taken, a large shard of glass (arrow) was readily detected. Despite its size, removal was difficult and time-consuming.

Figure 36-3 A, This patient has an obvious wooden foreign body on the dorsal aspect of the proximal part of the forearm. B, Manual removal of the object was not difficult. C, However, thorough exploration of the wound cavity via an incision over the entire length of the FB tract revealed multiple small wooden fragments. Proper exploration requires adequate analgesia, good lighting, hemostasis, and a cooperative patient. Use of a metal probe may help identify the foreign object by feel or sound (see Fig. 36-17).

Figure 36-4 A windshield forehead injury usually harbors multiple retained pieces of glass that are difficult to find. Probing with a needle or forceps to feel or hear contact with the fragments may help find them. A supraorbital nerve block is ideal to facilitate probing.

Figure 36-5 What’s wrong here? Though historically suggested as a useful technique to find foreign bodies, probing the depths of a wound with a gloved finger may result in a puncture wound in the operator. The practice is strongly discouraged because of the prevalence of hepatitis and human immunodeficiency virus infection.

Augmenting the Physical Examination: Imaging Techniques

Many emergency clinicians mistakenly believe that in the absence of adipose tissue, if the base of the wound can be clearly visualized and explored, an FB can always be ruled out. Orlinsky and Bright found the reliability of exploration to be related to the depth of the wound.³ In their study, only 2 of 133 superficial wounds, deemed adequately explored, had an FB on plain films, but 10 of 130 wounds had FBs beyond the subcutaneous fat despite negative explorations. Anderson and coworkers reported that 37.5% of the foreign bodies were initially missed by the treating physicians.⁴ In many of these cases, a radiograph of the injured area was not taken. Avner and Baker detected glass with routine radiographs in 11 of 160 wounds (6.9%) that were inspected and believed by the clinician to be free of glass.⁵ Clinicians evaluating for FBs should maintain a low threshold for ordering or performing imaging studies. Options for imaging include plain radiographs, ultrasound (US), computed tomography (CT), magnetic resonance imaging (MRI), and fluoroscopy. See Table 36-1 for a summary.

TABLE 36-1

Imaging Summary

A reasonable initial approach for localizing nonvisualized FBs in the ED is to obtain multiple-projection plain radiographs with a soft tissue technique. This technique will visualize the majority of FBs, especially metal and glass. US should be considered for objects known to be radiolucent, such as wood or thorns. The role of CT and MRI for evaluation of FBs in the ED is limited, but they are the definitive imaging tests in confusing cases. For suspected intraorbital or intracranial FBs, CT is recommended. CT or MRI is also warranted when a previously negative explored wound exhibits recurrent infection, poor healing, or persistent pain. CT or MRI may be the appropriate initial test for patients with nonspecific swelling to define FBs and possible alternative diagnoses such as abscesses, masses, or other inflammatory processes.⁶ Bedside US and fluoroscopy (for radiopaque FBs) may be used to guide difficult FB extractions if initial attempts at removal are unsuccessful and the proper equipment and experienced personnel are available.

3D, three dimensional; CT, computed tomography; ED, emergency department; FB, foreign body; MRI, magnetic resonance imaging; US, ultrasonography.

Plain Radiography

Plain radiographs are readily available, are easily interpreted, and cost significantly less than CT, formal US, and MRI do.⁷ The ability of plain films to detect FBs in soft tissue depends on the object’s composition (relative density), configuration, size, and orientation (Fig. 36-6). Detection of FBs on plain films can be enhanced by requesting an underpenetrated soft tissue technique and by obtaining multiple views to prevent FBs from being obscured by superimposed bone or soft tissue folds.⁸ Plain films are often sufficient; however, digitized radiographs may be manipulated to enhance identification of a suspected FB. Indirect evidence of an FB may include trapped or surrounding air, a radiolucent filling defect, or secondary bony changes such as periosteal elevation, osteolytic or osteoblastic alterations, or pseudotumors of bone.⁸

Figure 36-6 Radiographic appearance of various foreign bodies. Arrows point to glass (A), pencil lead (B) (graphite, but not wood, is radiopaque), and a metallic pin (C). Plain radiographs should be taken in multiple projections. Do not ignore subtle soft tissue irregularities. Generally absent on radiographs are aluminum, plastic, wood, thorns and other organic objects such as fish spines, and small pieces of gravel.

Metallic objects are readily visualized on radiographs. Despite a common misconception that glass must contain lead to be visualized on a plain radiograph, almost all glass objects in soft tissue (bottles, windshield glass, lightbulbs, microscope cover slips, laboratory capillary tubes) are at least somewhat radiopaque and can be detected by plain radiographs unless they are obscured by bone or are very small (<1 mm) (Fig. 36-7).^7,9,10 The absence of a glass FB on multiple projections is strong, though not absolute evidence that glass is not contained in a wound. Other nonmetallic objects readily visualized include teeth, bone, pencil graphite, asphalt, and gravel.^7,11 Aluminum, which has traditionally been deemed radiolucent, can occasionally be visualized on plain films if the object is projected away from the underlying bone. Ellis demonstrated that pure aluminum fragments as small as 0.5 × 0.5 × 1 mm could be identified in a chicken wing model simulating a human hand or foot.¹² Ellis cautioned that other aluminum FBs, such as pull tabs from cans, may not be visualized in other parts of the body such as the esophagus or stomach.¹²

Figure 36-7 Almost all glass is visible on a plain radiograph, regardless of its lead content. Do not ignore small white specs on a radiograph. If glass is superimposed on bone, it may be missed, so multiple projections are recommended. Plain film radiography shows sharp corners characteristic of glass. Proximity of the foreign body to the bone may be deceiving.

Certain FBs such as vegetative material (thorns, wood, splinters, and cactus spines) are radiolucent and not readily visualized on plain radiographs. These materials absorb body fluids as they sit in situ and become isodense with the surrounding tissue. Because of their varying chemical composition and density, plastics may or may not be visible on plain films.¹³

Besides simply diagnosing FBs, radiographs can also be used to estimate the general location, depth, and structure of radiopaque FBs. If one strategically attaches a marker (needle or paper clip) to the skin surface at the wound entrance before taking a radiograph, the FB will be seen in relation to the entrance wound (Fig. 36-8). This also helps identify the path that leads to the FB and the relative distance from the surface to the FB.¹⁴ Needles at two angles may also be used to aid in localization (Fig. 36-9).

Figure 36-8 A, This patient had an obvious diabetic foot abscess. B, A radiograph was taken to rule out osteomyelitis or soft tissue gas. To everyone’s surprise, including the patient’s, a sewing needle (arrow), origin and timing unknown, was the source of the infection. C and D, A paper clip was taped to the skin to localize the depth and position of the foreign body (FB; arrow) on the radiograph. An anteroposterior radiograph (not shown) also localized the FB. E, For orientation, the outline of the paperclip was traced on the foot. A dot marks a possible entrance site. F, A generous incision was made over the projected site of the FB. G, The needle (arrow) was felt and extracted with a hemostat. H, The wound was left open and packed with a cotton wick.

Figure 36-9 When a small entrance wound (A) is noted but the foreign body (FB) is not seen, noninvasive localization is preferable to blind probing. Metal markers taped to the skin or needles inserted close to the FB under local anesthesia (B) and radiographed at different angles provide a guide to localization and extraction of the FB. (Reproduced from Hospital Medicine, January 1981, with permission of Cahner’s Publishing Co.)

Liberal use of plain film radiography makes sound medicolegal practice. A review of 54 wound FB claims against 32 physicians from 22 institutions found glass, a radiopaque substance, to be the most common material. However, in only 35% of the cases involving glass were plain films taken. Cases with a glass FB without a radiograph ordered were associated with unsuccessful defense (60%) and higher indemnity payments.¹⁵

US

US has become the modality of choice for imaging radiolucent FBs such as wood and thorns because most soft tissue FBs are hyperechoic on US. In addition, if in place for more than 24 hours, most FBs will be surrounded by a hypoechoic area corresponding to granulation tissue, edema, or hemorrhage, which may aid in making the diagnosis.¹⁶ Metal will leave a linear trail of echoes deep to the FB, referred to as the “comet tail artifact.” A wooden object leaves an acoustic shadow without artifact.^17,18

US may be performed at the bedside. To do so, use a high-frequency transducer (at least 7.5 MHz, such as a high-frequency linear vascular probe) since most FBs are small and superficial. A lower frequency may also be necessary if a deeper FB is suspected, but it may miss small FBs.¹⁹ A spacer may be needed to adjust the “focal zone”—where the beam is the narrowest and signal intensity is the highest. US may be particularly difficult in the hand or foot, which have many echogenic structures and web spaces that may limit visualization when the FB is adjacent to bone.^16,18,20 Keep in mind that the presence of air, scars, calcification, sutures, and sesamoid bones in surrounding tissue may lead to false-positive results.^20,21

Advantages of US include low cost, no ionizing radiation, the ability to define the object in three dimensions, and real-time imaging, which may be used during removal.⁸ Many studies report that US is highly sensitive for the detection of FBs by adequately trained personnel, either radiologists, technicians, or emergency physicians.³ It is difficult to cite a precise sensitivity or specificity because of the wide variation in these studies with regard to FB size, material, and location; operator experience; and the models used in these studies.^21–23

Ultrasound

Foreign Body Removal by Christine Butts, MD

Many foreign bodies are radiopaque and can easily be seen with traditional radiography. Such foreign bodies include glass, metal, and some plastics. Other foreign materials, such as splinters, spines, and thinner plastics, are radiopaque and easily missed on radiographs. Ultrasound is an optimal modality for both identifying retained foreign bodies and aiding in their removal. A number of studies have evaluated the sensitivity and specificity of ultrasound in identifying foreign bodies in soft tissue. The findings have been variable, depending on the type and size of foreign body.1–3

General Considerations

A preliminary radiograph may be helpful in narrowing down the area to be evaluated with ultrasound, particularly when there is a large area where the foreign body may be found. Asking the patient to identify the point of maximal tenderness may also be helpful in narrowing down the overall area to be examined. Once the area has been clarified, a high-frequency (10 to 12.5 MHz) transducer should be selected. Higher frequencies will convey sufficient resolution to distinguish foreign material from normal soft tissue structures.

Each type of foreign body has specific identifiable characteristics; however, certain general findings suggest the presence of foreign material. The finding of soft tissue edema, represented by anechoic (black) or hypoechoic (dark gray) areas within the normal soft tissue, is highly suggestive of recent tissue disruption (Fig. 36-US1).

Figure 36-US1 Wooden foreign body in the foot. The foreign body is hyperechoic (arrow), whereas the surrounding hypoechoic region (arrowhead) is indicative of edema or pus. (From Rumack CM. Diagnostic Ultrasound. 4th ed. St. Louis: Mosby; 2010.)

The area in question should be evaluated from a number of different angles to find the object in its long axis. A small foreign body may easily be overlooked if only a small portion of it is seen.

Additionally, the use of a “stand-off” pad may be helpful, especially when dealing with superficial structures such as the hand or foot. A slim, fluid-filled structure, such as a 100-mL bag of saline or a glove filled with water, is placed over the area of interest. The transducer is then placed on top of this pad. This extra layer creates an acoustic window to allow greater resolution and eliminate some superficial artifacts that may impede the examination.

Metallic foreign bodies are strongly echogenic and are very straightforward to locate. They will appear bright white and often give off strong reverberation artifacts (Fig. 36-US2).

Figure 36-US2 Metallic foreign body identified as a brightly echogenic (white) object (arrow) with a comet tail artifact seen extending deep into the soft tissue (arrowhead).

Glass foreign bodies appear very similar to metallic objects in that they are highly echogenic (white). Glass may cause a reverberation artifact but more typically will cause acoustic shadowing to extend deep to the object (Fig. 36-US3).

Figure 36-US3 Glass foreign body (arrow) identified as a hyperechoic (white) object causing a strong shadow (arrowhead) within the otherwise normal-appearing soft tissue.

Wooden objects (such as splinters) are more challenging to locate, particularly with very small foreign bodies. Wooden foreign bodies do not create as strong an echogenic focus as other types of material do and may appear only slightly brighter than normal tissue (Fig. 36-US4). Very subtle shadowing may be seen extending deep to the object. The presence of surrounding edema is often key to locating the foreign body.

Figure 36-US4 Sonographic appearance of a retained wooden foreign body.

Removal

Once the object has been localized, it can be removed either blindly or under direct sonographic guidance.

Another technique that may be helpful, particularly with smaller objects, is to insert two 25-gauge needles under sonographic guidance. These needles should be inserted at right angles to each other so that the tips of each of them rest at the foreign body. The clinician can then cut the skin and overlying soft tissue and dissect down to the intersection of these two needles.

References

1. Orlinsky, M, Knittel, P, Feit, T, et al. The comparative accuracy of radiolucent foreign body detection using ultrasonography. Am J Emerg Med. 2000;18:401–403.

2. Schlager, D, Sanders, A, Wiggins, D, et al. Ultrasound for the detection of foreign bodies. Ann Emerg Med. 1991;20:189–191.

3. Dean, AJ, Gronczewski, CA, Costantino, TG. Technique for emergency medicine bedside ultrasound identification of a radiolucent foreign body. J Emerg Med. 2003;24:303.

CT

CT depends on x-ray absorption; thus, it generally visualizes the same material detected on plain films, but subtle differences in soft tissue densities may help identify FBs not seen on radiographs.7,11 Also, CT produces a better three-dimensional image than plain films do and may visualize objects embedded in or behind bone. However, CT is more costly and exposes the patient to more ionizing radiation than radiography or US does, and its use should therefore be judicious.

As an example, wood is unlikely to be visible initially on CT, but after 1 week, the wood absorbs surrounding blood products and may become higher in attenuation than muscle and fat. It may then appear on CT as a linear area of increased attenuation on a wide window setting such as a bone window.⁶

MRI

Although MRI is expensive and not as readily available to emergency clinicians as plain films and CT are, it may be superior to CT in detecting small, nonmetallic, radiolucent FBs such as plastic, particularly in the orbit.²⁴ MRI may not visualize wood, which may appear as a linear signal with associated inflammation and looks hypointense with respect to muscle on T1- and T2-weighted sequences, on which it appears as a signal void.⁶ Plastic is more easily visualized with MRI than with CT. MRI cannot be used for metallic objects and gravel, which contain various ferromagnetic particles that produce signal artifacts and a theoretical risk of shifting within the magnetic field and causing structural damage.⁷ This is particularly important when evaluating FBs in the eye, brain, or deep structures of the neck, face, or extremities. FBs may be difficult to differentiate from other low-signal structures on MRI, such as tendon, scar tissue, and calcium.²⁵

Fluoroscopy

More recently, portable, low-power, C-arm fluoroscopy has become available in some emergency departments (EDs), particularly for orthopedic reductions. Its use has also been reported for the removal of BB pellets, metal, glass, and coins from patients.²⁶ Like radiography, fluoroscopy can visualize objects that are radiopaque but not radiolucent such as wood and plastic.^26,27 By using correct technique and shielding, radiation scatter to imaging personnel is minute, less than 0.0001 R/hr.²⁸ Fluoroscopy also offers the advantage of real-time bedside imaging.^26,28 Fluoroscopic image-intensifying equipment may be used to follow a wound’s entrance, localize the material, grasp the FB, and remove it without making a larger incision. Ariyan described a technique in which two needles are placed in the soft tissue from opposite directions and pointing toward the FB.²⁹ The extremity is rotated while the clinician watches the image under the image intensifier to obtain a three-dimensional effect. An incision is made perpendicular to the plane of the needles, and the object is removed. Although the technique to use fluoroscopy is relatively easy to learn, the lack of instruction and availability is the major limitation to its use in the ED.^28–30

FB Removal

Removal Decisions

One should judiciously evaluate and manage each FB scenario individually. The composition and location of an FB, as well as the patient’s medical status and vocational and avocational activities, greatly affect decision making related to FB removal, including the best time and place for removal. Reactive material, such as wood, should be removed immediately when accessible because retained wood will invariably lead to inflammation and infection. Other inert material, such as glass or plastic, may often be removed on an elective basis. Some innocuously located glass and metallic FBs may frequently be left permanently embedded in soft tissue. With deeply embedded, small, inert material (BB, bullets, etc.) that is not located near any vital structures, the time, effort, and trauma involved in removal may be excessive when compared with the possible adverse effects of the foreign material remaining in place. An ill-conceived extended search for an elusive but otherwise harmless FB often results in frustration for the clinician and discomfort, dissatisfaction, and possible injury for the patient.

If localization is certain and removal can be accomplished within a manageable period without worsening of the injury, an attempt at removal is generally indicated on the initial visit (given the availability of clinicians and support staff).

When reviewing the decision regarding when and how to remove the FB, the possibility of the FB migrating to involve vital structures, though quite remote, should be discussed with the patient. Cases of reported missile embolization in the vascular system are influenced by missile caliber, impact velocity, physical wound characteristics, point of vessel entrance, body position and movement, and velocity of blood flow.³¹ Retained bullets usually remain in soft tissue but can rarely make their way into the vascular system. Schurr and colleagues reported a paradoxical bullet embolization from the left external iliac vein to the left iliac artery via a patent foramen ovale.³² When clinicians first examined the patient, a bullet was noted on the chest radiograph, and an isolated chest wound was suspected. However, the bullet had apparently entered the chest, traversed the abdomen to the iliac vein, and then embolized back to the chest and arterial system.

After the initial history, examination, and preoperative and preanesthetic documentation of the neurovascular status of the patient, a decision must be made regarding the time and place of removal. Thirty minutes is a reasonable self-imposed limit for the provider when attempting removal of an FB in the ED. More difficult procedures should be referred. Many FBs appear superficial on radiographs, thus suggesting that removal will be quite easy. However, surprisingly large or presumed superficial FBs still often prove quite elusive.

If an FB is left in place, inform the patient why it was not removed. If the patient is referred for delayed removal, this should also be carefully explained and documented. Regardless of whether the FB is removed, clean all wounds appropriately and update tetanus prophylaxis if indicated.

Equipment and Preparation

Good space and lighting, a comfortable patient and operator position, a standard suture tray, and a scalpel are usually adequate equipment for the removal of most simple FBs (Fig. 36-10). Tissue retractors, special pickups, and loupes may be added if needed.

Figure 36-10 The contents of a standard suture tray, with the addition of a scalpel, are usually adequate for the removal of most foreign bodies.

Local soft tissue injection or selected nerve blocks with buffered bupivacaine or lidocaine (or both) are the recommended anesthesia for the removal of most soft tissue FBs. Judicious use of sedation (parenteral, rectal, or oral) is advised if the clinician senses undue apprehension or anxiety in the patient. Sedation may be especially helpful in children, with ketamine often being an excellent choice. If the patient is totally uncooperative, postpone exploration to a more appropriate time and setting (e.g., under regional or general anesthesia in the operating room).

To successfully remove an FB in the soft tissue of an extremity, a time-limited arterial tourniquet can help provide a bloodless field. Inflate a blood pressure cuff or portable self-contained pneumatic cuff above arterial pressure on the upper part of the arm, forearm, leg, or thigh. To limit bothersome backbleeding, elevate the extremity and wrap it with an elastic bandage to exsanguinate the extremity before inflating the tourniquet. A Penrose drain or specialized tourniquet may be used as a tourniquet at the base of a finger or toe. Alternatively, use a sterile glove as a finger tourniquet. Cut the fingertip of the glove on the involved finger and roll the glove down to the base of the finger. Most patients can tolerate an ischemic tourniquet for 15 to 30 minutes, and it is safe to stop the circulation to an extremity for this length of time.

Operative Technique

The specific technique for removal of an FB is tailored to each clinical situation. In general, FBs should be removed only under direct vision. Grasping blindly into a wound with a hemostat to remove an FB should be avoided. This technique is especially dangerous in the hand, foot, neck, or face, where sensitive or vital structures may easily be damaged.

After obtaining appropriate informed consent and following sterile preparation, consider enlarging the entrance wound with an adequate skin incision, which can be advantageous. Numerous techniques are used, depending on the clinical scenario (Fig. 36-11). Attempting to remove an FB through a puncture wound or an inadequate skin incision is a common error that is both frustrating and self-defeating. After a proper skin incision, explore the wound carefully by spreading the soft tissue with a hemostat. Frequently, the FB can be felt with an instrument before it can be seen (see Fig. 36-11, plate 1). After placing a tourniquet on an extremity, follow the track of the FB, although it often cannot be identified when surrounded by muscle or fat. If the FB, such as one that is made of fiberglass or plastic, is difficult to visualize, is located in the superficial soft tissue, or has contaminated the surrounding soft tissue, excising a small block of tissue rather than removing the FB alone may be necessary. Excise the block of tissue only under direct vision and after nerves, tendons, and vessels have been identified and excluded from the excision area.

Figure 36-11 Foreign body (FB) removal techniques. (1 and 3, Reproduced from Hospital Medicine, January 1981, with permission of Cahner’s Publishing Co; 2, From Rees CE. The removal of FBs: a modified incision. JAMA. 1939;113:35. Copyright 1939, American Medical Association. Reproduced with permission.)

If an FB such as a thorn or needle enters the skin perpendicularly, a linear incision may pass to one side or the other of the FB, and it may be difficult to determine where the FB lies in relation to this incision (see Fig. 36-11, plate 2). For this reason the search must then be extended into the walls of the incision rather than simply through the skin.³³ In such cases, excise a small ellipse of skin and undermine the skin for 0.5 to 1.0 cm in all directions. Next, compress the tissue from the sides in the hope that the FB will extrude and can then be grasped with a hemostat.

After removal of the FB, it is important to irrigate and cleanse the wounds. If a small incision has been made in a noncosmetic area (such as the bottom of the foot), leave the incision open and bandaged. The area may be periodically soaked in hot water for a few days. A return visit is necessary only if signs of infection develop. If a large incision has been made, the skin may be sutured primarily as long as no other contraindications are present. In cases in which gross contamination has occurred or there is significant tissue injury, do not close the wound on the initial visit. Leave the wound open but packed. Suture the skin after 3 to 5 days if the wound is free of inflammation or infection (known as delayed primary closure; see Chapters 34 and 35 for details).

Special Scenarios and Techniques

Puncture Wounds in the Sole of the Foot

Puncture wounds in the feet from unknown objects and under unknown circumstances present problems to the clinician. In general, puncture wounds in the feet are at risk for retained FBs and infection. It is impossible to adequately explore a puncture wound. In noncosmetic areas, therefore, a puncture wound can be converted to a laceration to adequately explore and clean it (Fig. 36-12). Under most circumstances, delayed primary closure is recommended (see Chapter 34). This topic, including stepping on a nail and puncture wounds in the sole of the foot, are discussed extensively in Chapter 51.

Figure 36-12 This patient stepped on “something” while walking through a polluted urban creek, a setup for a foreign body and infection. Mandatory radiographs were negative. A, Under proper lighting (and a calf blood pressure cuff for a tourniquet), the patient is placed prone. Local lidocaine with epinephrine is infiltrated through the cut skin edges, not via the intact sensitive skin. (Alternatively, a posterior tibial nerve block could be used.) B, Inspection reveals a dirty skin flap that is cut off. C, Because a puncture wound cannot be explored or irrigated, this wound should be lengthened with a scalpel to allow further care. D, The depths of the wound are explored. E, An assistant holds the wound open with a hemostat so that copious irrigation can be accomplished. This wound should be packed open and checked in 24 to 48 hours, not closed primarily with sutures. Delayed closure can be performed in 4 to 5 days if necessary, but this injury healed well without sutures. Prophylactic antibiotics are of no proven value but may be given.

Subungual FBs

Once a subungual FB has been identified, perform a digital block before manipulation of the nail or nail bed. Pay special attention to deeply embedded subungual FBs.³⁴ Some cases may require removing a small portion of the nail with double-pointed heavy scissors to expose the FB and grasp the foreign material with splinter forceps (Fig. 36-13).

Figure 36-13 For a foreign body (FB) deep in the nail bed, take as small a wedge of nail as will allow access to the proximal end of the splinter, and then extract the FB with splinter forceps. All wood particles should be removed. A digital nerve block is usually necessary.

One technique is to bend the tip of a sterile hypodermic needle and slide it under the nail. Hook the FB and then remove it. Alternatively, slide a 19-gauge hypodermic needle under the nail to surround a small splinter. Bring the needle tip against the underside of the nail and secure the splinter. Remove the needle and splinter as a unit.³⁵ Another possible technique is to shave the overlying nail plate with a No. 15 scalpel blade via light strokes in a proximal-to-distal direction. This creates a U-shaped defect in the nail and exposes the entire length of the sliver.³⁶

Wooden splinters are commonly embedded under the fingernail. Such FBs must be removed completely because subsequent infection is almost certain. If complete removal cannot be achieved with the techniques described earlier, remove the entire nail (see Chapter 35). This allows all the fragments to be visualized and removed. The proximity of the distal phalanx to the subungual area is a constant concern for the development of osteomyelitis and requires follow-up.

Metallic Fragments and Bullets

High-velocity fragments (e.g., bullets, BBs) are easy to visualize radiographically and relatively simple to remove if embedded in areas that are anatomically accessible (Fig. 36-14). Before removal, assess the area in which the fragments are embedded to determine which structures are involved and which structures might be encountered during removal. Defer removal of deeply embedded metallic FBs unless symptoms of infection develop. Infection is rare because such FBs usually become encysted over time.

Figure 36-14 A and B, High-velocity fragments such as bullets or BBs are often easy to locate and visualize radiographically. Here, a BB is found embedded in the volar tuft of a finger. C, After a digital block, a small linear incision is made with a scalpel. D, The BB is removed without difficulty.

Surgery is rarely performed solely for the purpose of removing bullets. Retained bullets rarely cause complications or infection, and aggressive attempts to find and remove bullets generally cause more harm than good. Retrieval is often quite difficult unless the fragments are very superficial. Gunshot wounds themselves need no intervention beyond simple cleaning and perhaps minor débridement of the entrance or exit wound. Gunshot wound tracks do not need débridement unless there is gross contamination or significant tissue devitalization. Entrance or exit wounds should not be closed. Antibiotics are unnecessary for minor uncomplicated gunshot wounds but may be beneficial in patients with multiple injuries, gross wound contamination, significant tissue devitalization, large wounds, or delay in treatment.

A caveat is lead toxicity from bullet fragments. If a bullet is bathed in synovial, pleural, peritoneal, or cerebrospinal fluid, the lead may leach out over time and produce a significant elevation in blood lead levels. Though rare, lead fragments in contact with synovium are a reason for concern and potentially a reason for removal (see the previous discussion). In one study, Farrell and associates found that patients with retained lead FBs had statistically significant elevated blood lead levels.³⁷ The study did not differentiate the location of the FB and whether patients were, in fact, symptomatic from plumbism. Nevertheless, it may be prudent for the patient’s primary care provider to monitor blood lead levels in patients with known lead FBs to prevent the future development of lead toxicity. The value of routine prophylactic antibiotics for metallic FBs left in soft tissue has not been proved.

For superficial metallic FBs, a sterile magnet can be used to facilitate the removal of small metallic fragments.³⁸ Introduce the magnet into the entry site, with a small scalpel and hemostat used to extend and open the wound as needed. When the magnet comes in contact with the metal, a click is heard and the FB is removed while attached to the magnet. If resistance to extraction occurs, exploration can be done with the FB attached to the magnet. Sometimes, instead of introducing the magnet directly into the wound it can be placed on the overlying skin to guide superficial small FBs out of the wound.³⁹ Make an effort to not grasp or touch the bullet because it can interfere with ballistics evidence during any subsequent legal investigation.

FBs in Fatty Tissue

Remove FBs in fatty tissue by making an elliptical incision around the entrance wound. Grasp the incised skin loosely with Allis forceps. Undercut the incision until the FB is contacted. Remove the FB, skin, and entrance track in one block. Remove a small portion of subcutaneous fat along with the FB to minimize infection. FBs in fat are very mobile, and probing may displace them even further. FBs that are embedded in fat and are perpendicular to the skin can also be removed, as shown in Figure 36-11.

Pencil Lead/Graphite

Use careful judgment in removing pencil graphite when it is lodged in the skin. Graphite invariably leaves a pigmented tattoo in the soft tissue, and it is preferable to excise the material en bloc (see Fig. 36-11) when pencil lead is found in a cosmetic area. The graphite specks cannot be irrigated or scrubbed off, and tattooing results if they are not removed. Furthermore, a pencil lead FB may resemble a malignant melanoma over time. US has been shown to be useful in differentiating between pencil lead FBs and melanoma.⁴⁰

Fishhooks

Traditionally, four fishhook removal techniques have been described: advance and cut, string-yank, needle cover, and retrograde.⁴¹ The preferred method depends on the location, depth of penetration, and conditions under which the removal is to take place (Fig. 36-15).^42–44 Initially, note whether the fishhook is single or multiple. In addition, note the number and location of barbs. Remove or cover any remaining exposed hooks to prevent subsequent injury. As with most injuries, document the patient’s vascular and neurologic status before and after removal. As with all wounds, administer tetanus prophylaxis if indicated. Prophylactic antibiotics are not generally necessary.

Figure 36-15 Fishhooks. A, Fishing lure embedded in the nasal ala. This type of injury may occur while casting the line. B, Fish hook embedded in the distal tuft of the finger. Note that the barb is completely embedded in subcutaneous tissue, thus making removal by simply pulling the hook out impossible. C, This patient cut off the portion of the embedded hook external to the skin before coming to the emergency department. Patients will commonly do this; however, it makes removal more difficult because there is very little hook exposed that can be manipulated during attempts at removal.

Advance and Cut Technique: To perform the advance and cut technique for removal, advance the fishhook and cut proximal to the barb (Fig. 36-16, plate 1). This method is particularly well suited for superficially embedded fishhooks. Generally, infiltrate local anesthetic (1% lidocaine) into the tissue overlying the barb. Force the barb through the anesthetized skin and clip it off. Move the rest of the hook retrogradely, along the direction of entry. Because this technique is almost always successful, it can be considered a first-line option.

Figure 36-16 Fishhook removal. (Reproduced from Hospital Medicine, July 1980, with permission of Cahner’s Publishing Co.)

String-Yank Technique: In the field or stream, removal of a fishhook may be accomplished without local anesthesia by using the string-yank technique. This technique may be used in the ED as well. Some clinicians prefer to use local 1% lidocaine to facilitate removal. For the “stream” technique (see Fig. 36-16, plate 2), pass a looped string or fishing line around the belly of the hook at the point where it enters the skin. Wrap approximately 1 ft of string around the dominant hand to provide strong traction. Hold the shank of the hook parallel to and in approximation to the skin with the index finger of the opposite hand. Use the thumb and middle finger of the opposite hand to stabilize and depress the barb, which helps the index finger disengage the barb from the subcutaneous tissue. When the barb has been disengaged, give a sharp pull (i.e., a quick tug with a snapping motion) with the dominant hand to remove the hook. Take care to keep bystanders out of the expected path of the hook because it often flies out of the patient. A commercial fishhook extractor device is available that is based on this method. It is used to grasp the hook during removal (Minto Research and Development, Inc., Redding, CA).

Needle Cover Technique: For this technique use an 18-gauge needle to cover the barb (see Fig. 36-16, plate 3). After adequate local anesthesia has been achieved, pass the needle through the entrance wound of the hook parallel to the shank of the hook to sheath the barb and allow the hook to be backed out while the barb is covered. An alternative to this procedure is to insert a No. 11 blade parallel to the shank of the hook down to the barb and use the point of the blade to free the subcutaneous tissue that is engaged on the barb. Cover the barb with the point of the No. 11 blade and back the hook out, with the blade protecting the barb.

Retrograde Technique: This is the simplest, but least effective method. By applying downward pressure on the shank of the hook, disengage the barb to allow successful removal (see Fig. 36-16, plate 4). If resistance is encountered, abandon the procedure and attempt removal with another technique. If the barb is not already protruding from the skin, the retrograde technique may cause less tissue trauma.

Wooden Splinters

Removal of wooden splinters is a common FB removal procedure. By simply grasping the end of a superficial, protruding splinter, it may be adequately removed, but care should be taken to not leave small pieces of material in the wound. Some splinters cannot be visualized at the point of entry but can easily and readily be palpated beneath the skin. When a wood FB is in subcutaneous tissue, it is advisable to cut down on the long axis of the FB to remove it via a skin incision rather than pulling it out through the entrance wound (Figs. 36-17 and 36-18). Although an incision may seem extensive and creates a laceration where only a puncture wound existed, opening the track allows thorough cleaning and removal of all the small pieces of the splinter that might otherwise remain. If the incision is linear, it may be sutured. Occasionally, the fastest method of removing small wooden splinters is to completely excise the entrance track and the FB en bloc, followed by linear closure. Particular mention should be made of certain wood splinters that are pliable and reactive, such as California redwood and northwest cedar. Any wood that is easily fragmented requires meticulous care to ensure removal of all material.

Figure 36-17 A, The course and depth of penetration of this large wooden splinter in the leg are uncertain, but it is axiomatic that all pieces of wood must be removed to prevent infection. B-D, To ensure complete removal of foreign bodies, an incision is made over the entire course of the splinter. E-G, All pieces of wood are carefully removed under direct vision. H, The laceration is sutured primarily. Although it may be tempting to simply pull the splinter out and irrigate the puncture track, such actions often lead to retained particles and complications.

Figure 36-18 A, A splinter was removed from the foot of this 3-year-old 7 days earlier, and a few days after removal it began to swell. A retained foreign body (FB) was suspected. Plain radiographs were negative. A small pyogenic granuloma is seen. After ketamine sedation a 5-mm core of tissue was removed, but no FB was found on extensive exploration. This was an abscess from the puncture. The wound was packed open and cephalexin was given. B, It healed well (1 week later), but if it recurs, computed tomography or magnetic resonance imaging would be indicated to search for an occult FB.

Traumatic Tattooing

Ground-in foreign material or tattooing of the skin is a difficult problem because permanent disfigurement may occur (Fig. 36-19). These injuries occur most often from falls on blacktop surfaces or asphalt or falls from bicycles or motorcycles on a variety of surfaces. Many cases may be managed with adequate local anesthesia and meticulous débridement with a sponge, scrub brush, or toothbrush. If all foreign material cannot be removed with these methods, give careful consideration to secondary excision of the tattooed area and primary closure with subsequent plastic surgery to repair the defect. However, it is usually impossible to completely remove traumatic tattooing in the ED. Referral for more extensive surgical treatment after local wound care is quite acceptable. Dermabrasion may be an acceptable delayed treatment when the tattooing is superficial.⁴⁵ An alternative is to refer patients to a dermatologist for laser removal of traumatic tattoos. Certain lasers, such as a yttrium-aluminum-garnet (YAG) laser, have proved to be an excellent alternative.⁴⁶ The process is more specific in removing embedded material without harming the surrounding tissue. The type of material will determine the number of treatments required. Not all tattoos can be removed completely.⁴⁷

Figure 36-19 Traumatic tattoos. A, This patient was seen approximately 1 week after a blast injury. Traumatic tattoos are evident. The patient subsequently underwent successful laser removal of most of the pigment. B, Traumatic tattoo of the chin. Bluish discoloration and slight erythema, predominantly caused by silica, are apparent. (A, From Flint PW, Haughey BH, Lund VJ, et al, eds. Cummings Otolaryngology: Head & Neck Surgery. 5th ed. St. Louis: Mosby; 2010; B, from Bolognia JL, Jorizzo JL, Shaffer JV, eds. Dermatology. 3rd ed. St. Louis: Saunders; 2012.)

Marine FBs

Although most marine FBs, such as shell fragments, may be treated like other FBs, a number of marine animals carry toxins and may leave FBs that require special consideration. Saltwater marine FBs may be contaminated with Vibrio species, which are usually sensitive to tetracyclines, aminoglycosides, or third-generation cephalosporins. Even if all foreign material has been removed, stings from marine animals may initiate a prolonged local irritation that simulates cellulitis. However, the presence of a wound infection on a subsequent visit strongly raises concern for an occult retained FB rather than the simple conclusion that the wound is merely infected by bacteria introduced during the initial insult.

Coelenterates: Coelenterates, including the Portuguese man-of-war, true jellyfish, fire coral, box jellyfish, and sea anemones, inject several different toxins that are responsible for many marine envenomations by embedding venom-containing organelles, called nematocysts, into the victim’s skin (Fig. 36-20). The tentacles of coelenterates may contain thousands of nematocysts, which allows many to be deposited by even minor skin contact. After deposition, nematocysts discharge their venom. Reactions may be local or systemic, and the pain may be severe and is often described as “shocklike,” “itching,” “burning,” or “throbbing.” Substances such as tetramine, histamine, and 5-hydroxytryptamine are thought to be responsible for this localized reaction, whereas proteinaceous substances are implicated in the systemic response. Systemic reactions usually consist of fever, chills, and muscle spasm, but severe reactions may result in neurologic sequelae ranging from malaise and headache to paralysis and coma. Potential cardiopulmonary manifestations include dysrhythmias, hypotension, syncope, bronchospasm, laryngeal edema, and cardiorespiratory failure.^48,49

Figure 36-20 A, Magnified view of a venom-containing nematocyst in its resting or “cocked” state. After contact with the skin, a dartlike tail is extended and penetrates the dermis (B), and venom is injected (C). Further stimulation of the attached nematocyst can expel more venom (see text for the decontamination and removal technique).

Initial wound care should focus on decontamination and removal of unfired nematocysts, which will decrease the pain and systemic reactions. Vinegar (5% acetic acid) is the initial decontaminating agent of choice because it will inactivate the unfired nematocysts of most (but not all) species of jellyfish, Portuguese man-of-war, and sea anemones.48,50,51 Apply it continuously for 30 minutes or until the pain is gone.⁴⁹ Do not apply fresh water to the area because the osmotic shock will activate any remaining unfired nematocysts and cause them to discharge toxin and increase pain and toxicity. Other suggested, but unproven remedies include meat tenderizer, ammonia, baking soda, urine, olive oil, sugar, and papaya latex.

After the wound has been decontaminated, remove any remaining tentacle fragments. Extract large fragments with forceps; however, individual nematocysts are very small (<1 mm in length) and are not easily visible. To remove the remaining nematocysts, scrape the skin with a hard edge, such as a credit card held perpendicular to the skin. An alternative is to apply shaving cream and shave the area gently to eliminate the remaining fragments.⁴⁹ Do not used sand to remove nematocysts because sand can increase the discharge of venom. If the pain persists, it should be assumed that organelles still remain and further cleansing is required.

After decontamination, use topical anesthetics or steroids, but prophylactic antibiotics are not necessary. Follow routine wound care. Treat allergic and systemic reactions appropriately. The application of warm or cold packs to the area has not been shown to reduce pain.⁵⁰ Antivenin is available only for box jellyfish envenomation, but its use remains incompletely understood and controversial.

Coral: Coral is composed of a calcium carbonate core and thousands of small marine animals. Fire coral, a specific type of coral, is another type of coelenterate that produces toxicity with stinging nematocysts. After contact, a burning and intense pruritus may occur along with a series of skin eruptions. Within minutes of contact, pruritus, erythema, and urticaria-like lesions may appear, and blister formation may result within hours (Fig. 36-21). Eventually, the lesions will become lichenoid, but complete resolution may not take place for 15 weeks after contact. Ultimately, hyperpigmented areas will form at the point of initial contact. Immediate care with oral antihistamines and topical steroids tends to reduce, but not prevent the symptoms.

Figure 36-21 Fire coral stings. (From James WD, Berger TG, Elston DM, eds. Andrews’ Diseases of the Skin: Clinical Dermatology. 11th ed. St. Louis: Saunders; 2011.)

“Coral cuts,” which can be deep lacerations, occur in divers and snorkelers exploring coral reefs. With these wounds, delayed healing may take place with the secondary development of cellulitis or ulceration, perhaps as a result of contamination of the wound with bacteria or microparticles of coral.⁴⁸ Treatment consists of saline irrigation. Hydrogen peroxide may be used to help remove small coral particles from the wound.⁴⁸ Do not close the wound; wet-to-dry dressings are advised instead.

Sponges: Sponges produce both an irritant and a contact dermatitis. The irritant dermatitis occurs as a result of sponge spicules embedded in the victim’s skin. Remove the spicules with adhesive tape (applied to the skin and then peeled back), and then bathe the area with vinegar.⁴⁸ Contact dermatitis, which is believed to be caused by a toxin, produces erythema, pruritus, and vesicles similar to those with poison oak.⁴⁸ Treatment is initial immersion in vinegar followed by local steroid creams.

Sea Urchins and Starfish: Sea urchins and starfish are free-living echinoderms covered with venomous, sharp, brittle spines and with venom-secreting pincers located near the mouth. If sea urchins or starfish are handled or inadvertently stepped on, these spines may become embedded in the patient and a severe local reaction may result from venom in the spines. Systemic symptoms occur and include muscle weakness; paralysis of the lips, tongue, and face; hypotension; abdominal pain; and respiratory distress. Local pain responds quite well to immersion in hot water (43.3°C to 46.1°C [110°F to 115°F]) for 30 to 90 minutes. Retained spines may become infected or cause delayed (≤1 to 2 months) FB granulomas. This reaction is not adequately understood, but it may be due to an intense and persistent inflammatory reaction. Spines that penetrate joints may induce synovitis. Echinoderm spines may discharge a purple dye that may be mistaken for a retained spine (Fig. 36-22).⁴⁹ Spines are usually visible on radiographs and should be removed if possible, although they are brittle and can break off in the skin. A YAG laser may be an effective alternative to remove sea urchin spines. If spines are located in a joint or near a nerve, surgical extraction using an operative microscope may be necessary.⁴⁸ Otherwise, if removal is difficult, leave the spine in place until it is resorbed or a local reaction takes place. Open the wound and drain it to allow it to close by secondary intention.

Figure 36-22 A, Multiple sea urchin punctures in the hand soon after injury and following a soak in hot water. B, The same hand after 6 days without intervening therapy other than soaking. Lack of discoloration indicates absorption of dye from the sea urchin spines and probable absence of retained fragments. (From Auerbach PS, ed. Wilderness Medicine. 6th ed. St. Louis: Mosby; 2011.)

Catfish: Several species of catfish in North America contain toxic venom, and a sting from the dorsal or pectoral spines can embed an FB. The spine secretes venom from an epidermal gland at the base of the spine.⁵² The pain is usually ephemeral, and because no specific antitoxin exists, treatment consists of local care and analgesics. Immerse the affected part in hot water (≈43.3°C [110°F]) for at least 30 minutes if the pain is severe. This is believed to provide relief of symptoms by decreasing vascular and muscle spasm.⁵³ Local injection of the wound with alkalized bupivacaine provides local analgesia and may also neutralize the toxin.⁵² Inspect the wound and remove any remaining spines (Fig. 36-23). A radiograph may be taken to confirm the absence of FBs, but catfish spines and cartilage may be radiolucent. Bedside US may be helpful, depending on the clinician’s level of experience. Thoroughly clean and irrigate the wound. Update the patient’s tetanus prophylaxis if necessary. Some authors recommend empirical antibiotic therapy to cover gram-negative bacilli (e.g., Aeromonas hydrophila), but infection is quite rare and routine antibiotic prophylaxis is not standard.⁵²

Figure 36-23 To ensure total removal, remove the spine of a catfish by incising the puncture site as opposed to simply pulling it out.

Stingrays: Stingray envenomation usually occurs in a person who accidentally steps on a creature that is resting on the bottom in shallow water and covered by sand (Fig. 36-24). This causes the stingray to lash out its whiplike caudal appendage, or tail, which contains one to four venom-containing serrated spines. Portions of the spine may become buried in the victim’s skin. Each spine is covered with a sheath containing venom glands, and in addition to immediate toxin-induced pain, pieces of the spine or sheath may remain embedded in the wound. These fragments, though often difficult to locate, do not dissolve and must therefore be removed. Persistent pain and inflammation, even weeks to months after the attack, mandate consideration of a retained FB, but a persistent and difficult-to-treat irritative process can occur in the absence of a retained spine or sheath. Immediate local and systemic reactions develop as a result of injection of a complex toxin. Systemic reactions may be severe and can include muscle cramps, vomiting, seizures, hypotension, arrhythmias, and (rarely) death.⁵⁴

Figure 36-24 A, Stingray resting on the bottom of the ocean, usually covered by a layer of sand. B, An unsuspecting victim steps on the stingray, and the whiplike tail impales the foot (even through a heavy boot) with one or more spines. The spine has backward-facing barbs covered by a sheath with venom-containing cells (C), which causes a toxic envenomation and the potential for multiple foreign bodies.

Treatment consists of irrigation with saline followed by immersion in hot water at 42°C to 45°C for 30 to 90 minutes to inactivate the heat-labile toxin. Local digital blocks without vasoconstrictors provide effective analgesia for hand wounds. Explore and débride all wounds, and remove all remnants of the spine and integumentary sheath.⁴⁸ Wounds should heal by secondary intention. The venom can cause significant local tissue necrosis, and surgical débridement may be required.

Tetanus and Antibiotic Therapy: Prophylactic antibiotic therapy for marine injuries is common, although there are no convincing data to support or refute this practice. Unlike other soft tissue infections, marine injuries become infected with unusual gram-negative organisms, particularly Vibrio species. Although few studies have evaluated the effects of specific antibiotics, it is recommended that quinolones, trimethoprim-sulfamethoxazole, tetracyclines, third-generation cephalosporins, or aminoglycosides be used in lieu of penicillin, ampicillin, erythromycin, or first-generation cephalosporins.⁴⁹ It is always difficult to differentiate chronic inflammation caused by toxins and foreign material from true infection, and surgical exploration is often required in persistent cases. Administer tetanus prophylaxis as per routine recommendations.

Cactus Spines

The size of cactus spines fluctuates considerably. The difficulty of removal is generally inversely proportional to the size of the FB.⁵⁵ Larger embedded cactus spines are managed like wood splinters and sea urchin spine FBs. More advanced imaging techniques (US, CT, or MRI) may be required for localization of deeply embedded spines.

Deeply embedded cactus spines generally produce granulomatous reactions, but infections are rare.⁵⁶ Dermatitis from embedded cactus spines is a well-described phenomenon. Hence, make an effort to remove deeply embedded spines after carefully weighing the benefit and potential harm related to deep exploration, especially in a sensitive location.⁵⁵ Using forceps, remove superficially embedded, medium to large cactus spines by direct axial traction on each spine. Smaller spines (glochids) may be difficult and tedious to remove individually. Apply an adherent facial mask gel to remove the spines en masse with the gel (Fig. 36-25). Depilatory wax melted in a microwave oven and applied warm, commercial facial gels, and household glue (Elmer’s Glue-All, Borden, Inc., Columbus, OH) have all been recommended for this purpose.^55,57–59 Over-the-counter “home use” facial mask gels are not adherent enough to be effective without multiple (eight or more) applications.

Figure 36-25 A thousand or more glochids may become affixed to the skin by contact with a single pad of polka dot cactus. A, To remove them, professional facial gel is spread with a fan brush, thin at the edges. B, The gel rollup is started by picking at the edge with the fingernails. When the gel is peeled off, all the very small spines come with it. (From Lindsey D, Lindsey WE. Cactus spine injuries. Am J Emerg Med. 1988;6:362. Reproduced by permission.)

Ring Removal

Frequently, a ring must be removed to prevent laceration of tissue or vascular compromise. Thoroughly lubricate (with a water-soluble lubricant, e.g., K-Y jelly) the finger and use a circular motion with traction on the ring. However, the string-wrap method or physically cutting the ring off may be necessary. Preferably, remove all rings before the edema is extensive enough to cause pain or vascular compromise.

String-Wrap Method: An occasional patient can remain calm during this procedure, but if the swelling is significant or the digit has been traumatized, anesthesia is necessary. Perform a proximal digital or metacarpal block to provide sufficient anesthesia and to minimize tissue distention at the ring site. Before removal of the ring, wrap a wide Penrose drain circumferentially in a distal-to-proximal direction to reduce the soft tissue swelling (Fig. 36-26). Leave the wrap in place for a few minutes to reach the maximum effect. Some nonanesthetized patients panic during the procedure because of increasing pain from compression and unwinding.⁶⁰

Figure 36-26 Ring removal: string-wrap method.

First, pass a 20- to 25-inch piece of string, umbilical tape, or thick silk suture between the ring and the finger. Shorter lengths are discouraged because one may need to repeat the wrapping procedure midway. If marked soft tissue swelling is present, pass the tip of a hemostat under the ring to grasp the string and pull it through. Wrap the distal string clockwise around the swollen finger (proximal to distal) to include the proximal interphalangeal (PIP) joint and the entire swollen finger. Start the wrapping next to the ring. Wrap it snugly enough to compress the swollen tissue. Place successive loops of wrap next to each other to keep any swollen tissue from bulging between the strands. When the wrapping is complete, carefully unwind the proximal end of the string in the same clockwise direction to force the ring over that portion of the finger that has been compressed by the wrap. The PIP joint is the area that is most difficult to maneuver over and causes the most pain.

Occasionally, the finger must be rewrapped if it was not done carefully the first time. It is not uncommon to produce abrasions or other kinds of trauma in the skin during this procedure. If the finger with the ring is lacerated or there are underlying fractures, it is prudent to cut the ring off instead of attempting this technique.

Certain rings are made of extremely hard material such as tungsten carbide or ceramic. In these cases, cracking the material with standard locking pliers can break the ring. Place the pliers on the ring and adjust the jaws to fit tightly, and then remove and readjust them while increasing tension with each subsequent adjustment. Continue until the material cracks and falls apart. Some rings may be lined with a metal band. Use a standard ring cutter to remove the band.

Ring Cutter: A ring cutter should be used when the swelling is excessive or other methods fail (Fig. 36-27). A ring cutter has a small hook that fits under the ring and serves as a guide for the saw-toothed wheel that cuts the metal. The cut ends of the ring are spread with large hemostats (e.g., Kelly clamps), and the ring is removed. If the tension is too great to spread the ring, another cut 180 degrees apart from the original ring cut can be performed. This will allow the ring to fall off in two pieces. A jeweler can subsequently repair cut rings.

Figure 36-27 Ring removal: ring cutter method.

Certain hardened metal rings, such as tungsten carbide, may not be amenable to the use of a ring cutter. Case studies have demonstrated that a dental-tipped drill or dental volvere can be used successfully. However, because of the nature of these instruments and the possibility of injury from them, such as lacerations from the blade, thermal burns, or ocular FBs, take precautions to limit further damage to the finger, as well as the use of eye protection to shield the patient’s and operator’s eyes.

Body Piercing and Removal

The art of body piercing predates most history books. Over the last decade an enormous increase in the practice of body piercing has occurred. Accordingly, so have the complications associated with the practice.⁶¹ For centuries the ears were the most common place. Today, the lips, tongue, eyebrow, nose, navel, nipples, and genital areas have become sites of body piercing. To date, there are only a limited number of studies on infection after piercings in areas other than the ears. Three major types of jewelry are used: (1) barbell studs, which are straight bars with a ball threaded onto both ends; (2) labret studs, which are straight bars with a ball threaded on one end and a disk permanently fixed on the other end (more commonly used on the lips); and (3) a captive bead ring, which consists of a bead with small dimples on opposite sides and an incomplete ring with rounded ends to fit into the dimples (Fig. 36-28). The bead is held “captive” by tension from both sides of this incomplete ring. The bead ring is a variation of this: one bead is permanently fixed to one end, and an opening is made by removing the free end of the ring.⁶²

Figure 36-28 Various types of piercing jewelry. To remove a barbell stud or labret stud, unscrew the ball that is threaded onto the bar. To remove a captive bead ring, snap the ball out of the incomplete ring (it is held in place simply by tension and is not screwed in.) You may need to insert needle-nose pliers into the center of the ring and spread it to pry the ring open. To remove a bead ring, unscrew the ball from one end of the ring.

The most common reason for removal is infection (Fig. 36-29). Other symptoms such as bleeding, edema, allergic reaction, and keloid formation may also prompt removal. Occasionally, tongue piercings must be removed to permit intubation. To remove barbell- and labret-type studs, hold the bar with forceps and unscrew the bead on the other end. To remove a captive bead ring, hold the ring on both sides of the captive bead to release tension on the bead. This will dislodge the bead from the ring, which is holding it in place. If the jewelry is near the mouth or nose, take care to prevent aspiration of the bead. The complete microbiology of infections related to body piercing has not yet been determined. However, organisms such as Staphylococcus epidermidis and Staphylococcus aureus, along with Pseudomonas aeruginosa, have been commonly implicated pathogens. Other infectious complications from body piercing such as septic arthritis, endocarditis, hepatitis B and C, and HIV have been reported.^63,64

Figure 36-29 Body piercing removal. This piercing became infected when the mucosal portion of the metal bar migrated into tissue. An incision was required to find and grasp the metal bar.

Most commonly, however, local wound infections predominate and can be managed with warm compresses, antibacterial soap, and topical antibacterial ointment once the FB is removed. The possibility of leaving the piecing in place while treating the infection has yet to be studied.

Postoperative Suture Removal

FBs in the form of nonabsorbed suture material are frequently encountered in the postoperative period. Drainage, localized pain, tenderness, and an inflammatory reaction along the suture line are characteristic of a retained FB (suture abscess). In this instance, probing the wound with a sterilized needle bent into the shape of a crochet hook is frequently successful. Hooking the suture material through the sinus tract and removing it allows the wound to heal over the tract.

Tick Removal

It is important to remove ticks early because the hard tick of the Ixodid family is likely to transmit disease. Rocky Mountain spotted fever, Lyme disease, tularemia, and ascending paralysis are among the many infections identified as tick-borne diseases. It is important to note that the rate of disease transmission before 48 hours of attachment is exceedingly low.⁶⁵ Removal of Ixodid ticks is difficult because the mouthparts become cemented within 5 to 30 minutes of contact with the host’s skin. Removal will become more difficult the longer the tick is attached. Inadequate or partial removal of the tick may cause infection or chronic granuloma formation. Removal by mechanical means is recommended.⁶⁶ Nonmechanical, traditional, and folk methods of forcing the tick to disengage (e.g., the use of petroleum jelly, fingernail polish, a hot match, or alcohol) are not advised and can cause the tick to regurgitate, thereby increasing the possibility of transmission of infection.

The use of straight or curved forceps or tweezers is the recommended method of removal. If these instruments are not available, use a gloved hand. Grasp the tick as close to the patient’s skin surface as possible and gently apply steady axial traction (Fig. 36-30). Take care to not squeeze, crush, twist, or jerk the tick’s body because this may expel infective agents or leave mouthparts in the skin. If mouthparts are left behind after removal of the body, they may be removed with tweezers. If one is still unable to remove the mouthparts, consider excision under local anesthesia to prevent local infection.

Figure 36-30 Tick removal.

Many patients have great anxiety about the development of tick-borne diseases after tick removal. Some studies have demonstrated that single-dose doxycycline (200 mg) may prevent the development of Lyme disease.⁶⁵ Children younger than 8 years may be given a single dose of doxycycline (4 mg/kg). However, prophylactic antibiotic treatment of all tick bites is not recommended. Amoxicillin prophylaxis is not effective. When a patient is in an area where the incidence of Lyme disease is high or when a partially engorged deer tick in the nymphal stage is discovered on the body, the patient is more likely to benefit from prophylaxis. Regardless of whether prophylaxis is given, instruct patients about the symptoms and signs of Lyme disease and encourage them to return or seek medical evaluation if these symptoms develop.

Zipper Entrapment

The skin of the penis may become painfully entangled in a zipper mechanism (Fig. 36-31). Unzipping the zipper frequently lacerates the skin and increases the amount of tissue caught in the mechanism. Although the clinician may anesthetize the skin and excise the entrapped tissue, a less invasive method can be considered.

Figure 36-31 Penile skin caught in a zipper creates a rather painful and embarrassing situation for the patient. Instead of anesthetizing and excising the skin, consider cutting the zipper as demonstrated in Figure 36-32.

Cutting the median bar between the faceplates of the zipper mechanism remains the most common method. The interlocking teeth of the zipper then fall apart when the median bar (diamond or bridge) of the zipper is cut in half (Fig. 36-32), and the skin is subsequently freed. A bone cutter or wire clippers and a moderate amount of force may be required to break the bar. The addition of mineral oil followed by traction has been demonstrated to achieve some success. Patients with penile lacerations warrant urologic follow-up to assess for urethral injury.

Figure 36-32 Zipper removal. (From Emergency Medicine, October 15, 1982, p. 215. Used by permission.)

Infiltration of Radiographic Contrast Material

The infiltration of high-osmolality intravenous contrast material has the potential to cause skin necrosis, but the use of low-osmolality dye, which is well tolerated in soft tissues, has essentially eliminated this problem (Fig. 36-33). The use of high-pressure power injectors, with the technologist out of the room, calls for careful inspection of the intravenous site before injection. However, because of the high-pressure rapid auto-injection of contrast material and the absence of a technician in the room, extravasation of contrast material is not a rare event and occurs even with meticulous technique. Infiltration occurs in about 0.5% to 1% of auto-injections. Once contrast material has infiltrated, no intervention has been demonstrated to ameliorate the local reactions, which are usually mild. Swelling, erythema, and mild discomfort at the infiltration site may occur. It is best to resist the temptation to use excessive heat or cold. Elevation of an extremity is appropriate but of unproven value. Injection of steroids and other agents has no known benefit. Low-osmolality dye is usually totally resorbed in a few days, with no serious consequences in the vast majority of cases. Progress of the dye’s egress may be followed with radiographs. The majority of contrast material extravasations resolve with no long-term consequences with conservative management. If large volumes of contrast material are injected (>75 to 100 mL), especially in confined areas such as the dorsum of the hand, it is possible that skin necrosis from the pressure or a compartment syndrome may develop, but this is rare. The clinician should resist attempts to routinely remove even large volumes of extravasated contrast material by incision or aspiration. Although some contrast material may be removed with surgical techniques during fasciotomy, the actual benefit is unknown. Surgical intervention is rarely required and is based on measurement of compartment pressure and clinical evaluation. Patients with small-volume and minimally symptomatic extravasations may be discharged. Large-volume extravasations warrant consultation or further observation.

Figure 36-33 The entire volume (100 mL) of nonionic low-osmolality contrast material (Isovue) for a computed tomography scan was pressure-injected into the antecubital soft tissue when the intravenous line infiltrated. High-volume injections are automatically administered by a programmed autoinjector; the technician is not in the room to stop it. A, There was only mild pain but considerable soft tissue swelling, and most of the redness and blistering occurred when the technician taped an unprotected ice pack directly to the skin and nearly caused frostbite. B, X-ray evidence of the infiltration. C, Within 36 hours, the dye was absorbed, without further treatment. No skin necrosis occurred, as has been seen when older ionic high-osmolality agents infiltrate. There is no known proven way to ameliorate the potential soft tissue injury. The antecubital fossa is the preferred site for an intravenous live for injection of contrast material, and such an extravasation on the dorsum of the hand may be more serious. Do not attempt to remove the contrast material by aspiration or surgical incisions.

TASER Darts

The Thomas A. Swift Electric Rifle, or “TASER,” is a conducted electrical weapon used in many areas by police to subdue violent patients (see Chapter 70). The TASER fires two barbed electrodes on long copper wires (Fig. 36-34). The barbs attach to skin or clothing and create an arc that delivers an electrical jolt that causes overwhelming pain and involuntary muscle contraction and incapacitates the subject. The electricity is of such high frequency that it is believed to stay near the surface and not penetrate to the depth of internal organs. The barbs are designed to not penetrate deeper than 4 mm, and police are taught to remove them by stretching the surrounding skin and tugging sharply. If this fails, cutting down on the dart after local anesthesia should facilitate removal.^67,68 Patients may need medical evaluation after ED removal of the darts for the underlying state of agitation that required the use of a TASER, complications of electrical injury, injury from the fall after incapacitation, and injury from the barb, especially if struck in the mouth, eye, neck, or groin. Most patients do well with minimal intervention and proper wound management if the patient is not unduly agitated and the TASER did not involve the critical areas of the body just mentioned.

Figure 36-34 A and B, Barbed TASER darts can be removed by a quick pull or through a small incision made over the barb.

Human and Animal Bite FBs

The most common FB after a human bite is a piece of tooth. These FBs can be difficult to find and may not be appreciated if the patient does not admit or disclose the bite wound. Usually, the bite puncture is small and not easily cleaned or visualized. The puncture can be widened with a formal incision to aid in cleaning and evaluation for tendon integrity, injury to the joint capsule, fracture, or an FB (Fig. 36-35). Occasionally, small pieces of teeth can become embedded in a wound, such as with dog, cat, or snake bites (Fig. 36-36). Radiographic detection is variable, and exploration is often the only alternative.

Figure 36-35 This human bite puncture wound was enlarged with an incision to aid in cleaning and search for a foreign body, usually a piece of tooth.

Figure 36-36 A, The bite of a boa constrictor, though not poisonous, may contain small tooth fragments (B). As with cat and dog bites, radiographic evaluation is variable and exploration may be required.

Pyogenic Granuloma (Lobar Capillary Hemangioma)

A pyogenic granuloma is a benign acquired polypoid, friable vascular lesion of the skin (hand, neck, foot, fingers, and trunk) and mucous membranes (Fig. 36-37). They are common in children; in pregnancy the lesion is termed epulis gravidarum (pregnancy tumor). The cause is unknown, but there is some association with topical retinoids and the protease inhibitor indinavir; they are not due to infection, and they are not granulomas. They grow rather rapidly over a period of a few weeks, are occasionally associated with minor trauma, have a glistening dark red appearance, and may bleed. Histologically, a pyogenic granuloma is a hemangioma. A variety of topical therapies (silver nitrate, cryotherapy), laser, or cautery is available, but removal by sharp dissection with primary suturing is usually curative (Fig. 36-38). The recurrence rate may be as high as 40% with nonsurgical intervention.⁶⁹

Figure 36-37 Pyogenic granuloma. Despite their name, these lesions are neither pyogenic (i.e., infectious) nor granulomas. Rather, they are a type of hemangioma. Pyogenic granulomas can develop rapidly over a period of weeks and are common in pregnant women.

Figure 36-38 A-D, Pyogenic granuloma removed by sharp dissection under ketamine anesthesia and primary suturing.

Hair-Thread Tourniquet

Hair or thread fibers adherent to infants’ clothing occasionally become tightly wrapped around a child’s digits or genitals (Fig. 36-39).⁷⁰ If they are left in place, amputation may eventually occur. The offending fibers may be difficult to visualize, and the child is often brought for evaluation only after signs of distal ischemia appear. Occasionally, the fiber can be grasped with toothless forceps or a small hemostat and then be unwrapped. More commonly, fibers cannot be identified because they are deeply embedded in swollen tissue. Removal not requiring minor surgery includes use of a chemical depilatory, such as the over-the-counter product Nair (calcium thioglycolate), to dissolve or weaken the hair. A generous amount of depilatory cream is worked into the involved area and allowed to dissolve or weaken the hair, which is then removed mechanically. If a depilatory is not successful in 30 to 60 minutes, surgical removal is indicated.

Figure 36-39 This child has multiple hair tourniquets compromising the circulation to two toes. The hairs are deeply embedded in the skin creases and cannot be visualized. An over-the-counter depilatory (such as Nair) smeared into the fold may dissolve the hair in 30 to 45 minutes, but if unsuccessful, an incision must be performed. The best way to ensure removal of the constriction is to cut the depth of the folds with a scalpel blade (using a dorsal incision to avoid the neurovascular bundle) and attempt to extricate individual fibers. A digital nerve block may be performed for anesthesia. Return of circulation should be obvious by the change in temperature and color in the affected digit or digits before it is assumed that all the fibers have been cut.

A No. 11 blade can be used to cut the constricting bands under a regional nerve block.⁷¹ It may be difficult to identify individual hairs that are deeply embedded in a swollen digit and even more difficult to assess the success of the intervention. Frequently, multiple hairs are involved. Because the bands may be quite deep, the incision should avoid known neurovascular tracts. Barton and coworkers recommend a dorsal, rather than a lateral incision on the digits.⁷⁰ If the soft tissue on the distal end of the digit has been rotated after a circumferential dermal laceration from the tourniquet, the distal tissue can be realigned with the proximal tissue and two dorsolateral sutures placed or tissue adhesive glue applied to maintain the digit in alignment.

Generally, conservative wound care is sufficient once the band has been removed. Application of an antibiotic ointment may enhance healing and allow easier removal of serous drainage from the circumferential laceration. Clinical reassessment in 24 hours will indicate whether any constricting bands remain.

Disposition Management

Tetanus

Wounds with FBs should be considered contaminated wounds, and tetanus status should be updated according to the recommendations for patients with contaminated wounds.

Antibiotics

There is no consensus or standard for the use of antibiotics after removal of wound FBs. Antibiotics may be indicated for immunocompromised patients, but there are no data to support the routine use of antibiotics in patients with wounds that have been thoroughly cleaned and from which all foreign material has been extracted. Prophylaxis may be considered if there was excessive time between injury and removal or obvious contamination or when it is difficult to adequately clean the wound. Under these circumstances it is more prudent to opt for an open wound and delayed closure.

If prophylactic antibiotics are prescribed, a first-generation cephalosporin or penicillinase-resistant penicillin has traditionally been the first-line choice. In patients with contraindications to penicillins and cephalosporins and with the increasing incidence of community-acquired methicillin-resistant S. aureus in many areas, clindamycin, trimethoprim-sulfamethoxazole, or tetracycline may provide alternative coverage.⁷² However, infections associated with FBs are not likely to be from methicillin-resistant S. aureus. Under certain circumstances, alternative antibiotics may be indicated. For infected plantar punctures through a shoe, a fluoroquinolone to cover P. aeruginosa is appropriate coverage, although most Pseudomonas infections are complex and may need extensive débridement and intravenous antibiotics. Saltwater marine FBs may be contaminated with Vibrio species, which are usually sensitive to tetracyclines, aminoglycosides, or third-generation cephalosporins. Freshwater FBs, on the other hand, are more likely to harbor A. hydrophila, which can be treted with tetracyclines.

FB Reactions

If the FB is not removed or cannot be removed, an FB reaction may occur. Some FBs produce an inflammatory reaction or infection a few days after introduction into the body. Other objects may not cause problems for weeks, months, or even years until they flare up for no apparent reason. The primary factors that affect the extent of tissue reactions are contamination and whether the material is inert or reactive with human tissue. Reactive FBs, such as wood, will always produce inflammation eventually, whereas inert FBs, such as bullets, rarely do. Some inert FBs carry dirt particles, pieces of clothing, or other sources of bacterial contamination. Expeditious removal may be necessary, even if the FB itself is relatively small and unlikely to cause a reaction.

A purulent bacterial infection may develop in the presence of any FB; therefore, any abscess or cellulitis that recurs or wounds that do not heal as expected should always be investigated for retained FBs.73,74 Karpman and coworkers found a 15% rate of infection (S. aureus and Enterobacteriaceae) in a series of 25 patients treated for cactus thorn injuries on the extremities.⁵⁶ Certain thorns (black thorns, rose thorns), redwood and northwest cedar splinters, toothpicks, hair, and stingray or sea urchin spines are noted for their ability to initiate chronic FB reactions. Sea urchin spines and other marine FBs are covered with slime, calcareous material, and other debris that commonly initiate an FB granuloma. The inflammatory reaction seen with cactus thorns may be an allergic reaction to fungus found on the cactus plant.

Many FB reactions are thought to result from an inflammatory response to organic material, or they may represent infection from bacteria introduced at the time of the wound. Clinically evident reactions may be delayed for weeks or even years after injury (Fig. 36-40). The chronic infection or inflammatory reaction may not be accompanied by the production of pus, but it may be quite painful or result in loss of function. FBs may also be associated with the formation or development of a chronic pseudotumor, a sinus tract, or an osteomyelitis-like lesion of bone and soft tissue.⁷³ In addition, organic material has been noted to induce chronic tenosynovitis, chronic monarticular synovitis, and chronic bursitis.

Figure 36-40 This foreign body (FB) granuloma developed after the FB was stable for 6 months. There was no gross infection and it was dissected en masse.

Rapidly traveling projectiles with considerable inherent heat (e.g., bullets) are less likely to cause infection but are more apt to cause other difficulties. Damage to surrounding areas can occur during passage through tissue. Rarely do retained lead FBs, such as bullets or shotgun pellets, leach out lead into the general circulation and produce systemic lead poisoning unless they are in contact with synovium (Fig. 36-41). If this process does occur, it may take years to develop and can result in vague or nondescript symptoms (e.g., fatigue, arthralgia, headache, or abdominal pain) many years after the initial injury. Elevated blood lead levels are more likely to occur if body fluids such as joint, pleural, peritoneal, or cerebrospinal fluid bathe the lead. Bullets retained in muscle or other soft tissue are not likely to produce any sequelae related to their lead content. However, Farrell and colleagues reported unsuspected elevated lead levels in patients with retained lead fragments who were seen in the ED with a variety of complaints.⁷⁵ Lead levels of up to 50 µg/dL were reported. Levels greater than 45 µg/dL are generally considered an indication for chelation therapy. The relationship between the retained lead and the symptoms was unclear, but this report verifies the observations of others that retained lead FBs in selected areas can significantly elevate blood lead levels and may produce symptomatic plumbism.