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Wooden Splinter-Induced Extremity Injuries: Accuracy of MRI Evaluation

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Wooden Splinter-Induced Extremity Injuries: Accuracy of MRI Evaluation The Egyptian Journal of Radiology and Nuclear Medicine (2013) 44, 573–579 Egyptian Society of Radiology and Nuclear Medicine The Egyptian Journal of Radiology and Nuclear Medicine www.elsevier.com/locate/ejrnm www.sciencedirect.com ORIGINAL ARTICLE Wooden splinter-induced extremity injuries: Accuracy of MRI evaluation Mohamed Ragab Nouh a,d,*,1, Ahmed Mohamed Sabry Nasr b,2, Mohamed Osama El-Shebeny c,3 a Department of Radiology, Faculty of Medicine, Alexandria University, Alexandria, Egypt b Department of Radiology, Faculty of Medicine, Zagazig University, Zagazig, Egypt c Department of General Surgery, Damanhour Teaching Hospital, Damanhour, Egypt d Department of Radiology, Al-Razi Orthopedic Hospital, Sulibikhate, Kuwait Received 8 January 2013; accepted 3 June 2013 Available online 27 June 2013 KEYWORDS Abstract Objective: To detect the accuracy of MR imaging in detection and localization of woo- MRI; den splinters invading the extremities using surgical data as a reference standard. Wooden splinters; Methods: A retrospective review on a series of eighteen patients with: history of wooden foreign Extremity swellings body penetration and/or localized swellings to their extremities, surgically confirmed final diagnosis of wooden foreign body penetration and having both screening X-ray and MR imaging of their concerned extremities. MR imaging included variable combination of fast-spin echo imaging in T1W and T2W without fat-suppression as well as fat-suppressed proton density and/or STIR sequences. Gadolinium- enhanced imaging was available in 10 of the MR studies of our patients only. Results: Successful localization using MR was achieved in sixteen patients only, in the current study with sensitivity and specificity of 88.8%. Wooden splinters were recognized as linear signal * Corresponding author. Address: Department of Radiodiagnosis, Faculty of Medicine, Alexandria University, Alexandria 21599, Egypt. Tel.: +20 65099562/24825909; fax: +20 24825508. E-mail addresses: [email protected], [email protected] (M.R. Nouh), [email protected] (A.M.S. Nasr), oelshebeny@g- mail.com (M.O. El-Shebeny). 1 Department of Radiology, Al-Razi Orthopedic Hospital, Gamal Abd El-Naser Street, Sulibikhate 13001, Kuwait. 2 Department of Radiology, Chest Hospital, Sulibikhate, Kuwait. Tel.: +965 226380591. 3 Tel.: +20 453318222. Peer review under responsibility of Egyptian Society of Radiology and Nuclear Medicine. Production and hosting by Elsevier 0378-603X Ó 2013 Production and hosting by Elsevier B.V. on behalf of Egyptian Society of Radiology and Nuclear Medicine. http://dx.doi.org/10.1016/j.ejrnm.2013.06.001 574 M.R. Nouh et al. void on T1, T2 and PD weighted images surrounded by reactive inflammatory changes. In the remaining two cases, wooden splinters were missed on MRI due to their tiny size. Conclusions: Characteristic target appearance of signal void wooden splinter and surrounding inflammatory changes on MR imaging of unusual soft-tissue masses of the extremities should alert radiologist to the possibility of wooden-splinter induced granuloma. Ó 2013 Production and hosting by Elsevier B.V. on behalf of Egyptian Society of Radiology and Nuclear Medicine. 1. Introduction Patient’s age, sex, occupation and accidental circumstances associated with foreign body injury were recorded to evaluate Most foreign body (FB) injuries to the extremities commonly patient’s demography. occur during daily activities and in the context of occupational All patients had X-ray screening of their concerned extrem- exposures (1). Patients usually present with non-specific symp- ities at initial presentation. MR imaging evaluation of all pa- toms such as pain and/or swelling and it will be a predicament tients was carried out on 1.5T units. In our institution, if no previous history of trauma is recognized, making its extremity imaging is carried out using a suitable size flexible detection important to avoid serious complications (2,3). coil or a quadrature send-receive knee coil. The patient is Plain X-ray screening to exclude foreign bodies after trau- immobilized in a comfortable position to limit possible exhaus- ma is a widely used practice (2,3). Yet, it is unrewarding for tion-induced motion artifacts. The imaging series usually in- non-radiopaque foreign bodies such as wood that frequently cludes variable combination of fast-spin echo imaging in remain undetected and represent a diagnostic challenge, espe- T1W spin-echo (SE) (TR/TE = 500/12, NEX = 2) and T2W cially if foreign body penetration history is uncertain (2,4). fast spin-echo (FSE) (TR/TE = 4500/80, NEX = 3) without Ultrasound (US) provided an excellent alternative method fat-suppression in sagittal, short-axis (coronal) and long axis for identifying, localizing and even retrieval of radiolucent for- (axial) planes of the foot. Additional fat-suppressed proton eign bodies (4–6). Some researchers emphasized the role of density (TR/TE = 3000/35) and STIR (TR/TE = 5400/45, computed tomographic (CT) scanning and magnetic resonance TI = 140) sequences may be acquired in best planes to opti- imaging (MRI) in the detection of many foreign bodies that mize the concerned anatomy and allow good delineation of may be missed on radiographs (7–9). Few reports addressed the pathologic findings. Gadolinium-enhanced imaging was the role of MRI in the evaluation of wooden foreign bodies available in 10 of the MR studies of our patients. in human extremities (10–12) while the major bulk of literature All radiographic and MR imaging studies of our patient’s descriptions are based on case studies. population were reviewed by the authors in consensus. The purpose of this study was to detect the accuracy of MR The radiographic studies were assessed for the presence of imaging in detection and localization of wooden splinters bony changes including cortical fractures and periosteal reac- embedded in the extremities using surgical data as a reference tion as well as soft-tissue changes e.g. increased densities, pres- standard. ence of gas and/or swellings. The MR images were evaluated for the presence of a signal 2. Materials and methods void foreign body, soft-tissue edema and/or collection, mass and/or abscess formation as well as the presence of any adja- Following our medical ethics committee approval exempting cent bony changes or articular abnormalities. individual informed consent acquirement, we carried out a ret- Twelve patients were found to have had targeted US exam- rospective study on a series of patients presented to our insti- inations at outside facilities prior to presenting to our institu- tution; over a period of 12 months (between 1st April 2010 and tion. Studies were performed to evaluate their localized soft 31st March 2011); using our institutional data and minor pro- tissue swelling and/or site of suspected foreign body entry. cedure registries. None of our cases underwent CT or invasive procedures such Our study population included 18 patients (16 males and 2 as sinography. females) achieving the following inclusion criteria: 3. Results (a) Patients with suspected wooden foreign body penetra- tion presented with painful extremities with or without All relevant patients’ data were processed and analyzed as re- localized swellings. gards their demographic, clinical and imaging perspectives. (b) Patients had plain X-rays that were negative for radio- 3.1. Demographic and clinical data opaque foreign bodies. (c) Patients underwent MR imaging in their diagnostic work up to search possible non- radiopaque foreign Our study population included 18 patients, two (11.1%) fe- bodies. males and sixteen (88.8%) males with an age range of 3– (d) Patients with surgically confirmed final diagnosis of 50 years (mean age, 23.94 years). wooden foreign body penetration. Seven (38.8%) of our patients were uncertain of previous traumatic history while the remaining eleven (61.1%) patients Patients with surgically confirmed non-wooden foreign gave a previous history of antecedent skin puncture and/or pe- bodies e.g. glass pieces and stones were excluded from our netrating injury. In this latter group, the time interval between study population. inciting injury and presenting symptoms varied between Wooden splinter-induced extremity injuries: Accuracy of MRI evaluation 575 14 days and 8 months with a mean average interval of 68.5 days. Clinically, localized extremity swelling was the commonest presenting symptom in the current work (Table 1). Anatomi- cally; sole of the foot was the commonest target for wooden splinter among our study population, (Table 2). 3.2. Radiographic examinations Soft-tissue swelling accompanied by osteomyelitis of the ulna was seen in a 3 year old child (Fig. 1). Subtle soft tissue fullness of the dorsum of the foot was noted in another case. The remaining sixteen cases had unremarkable radiographic stud- ies. None of the wooden splinters was detected on X-ray in our series. 3.3. MRI examinations Sixteen of our patients revealed the wooden splinters as signal void structure on T1, T2 and PD weighted images surrounded by reactive inflammatory changes manifest as low signal on T1W images and high signal on T2W and PDW images. Five of them showed the wooden splinters in a leading sinus tract connecting it to the adjacent superficial skin; either in foot or hand. The remaining eleven cases showed variable inflam- matory reactive changes including: abscess formation (Fig. 2); muscle edema (Fig. 3), and indurated inflammatory mass (Fig. 4); within the involved extremity. All 10 cases in which intravenous gadolinium administra- Fig. 1 (a and b): a 3 year old boy fell on a palm stent while tion was utilized demonstrated peripheral enhancement of playing and a palm thorn was then removed from his forearm by the inflammatory reaction surrounding the wooden splinters. his father who subsequently took him to the emergency depart- Central liquefaction and abscess formation surrounding the ment. Initial radiograph showed no abnormalities. (a) Three weeks embedded FB were noted in two cases. Mild enhancement of later, the child presented with a painful swollen forearm along calcaneal marrow, believed to be due to reactive marrow ede- with low grade fever.
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