Management of Foreign Bodies in the Skin GWEN WAGSTROM HALAAS, MD, MBA, University of Minnesota Medical School, Minneapolis, Minnesota Although puncture wounds are common, retained foreign bodies are not. Wounds with a foreign body sensation should be evaluated. The presence of wood or vegetative material, graphite or other pigmenting materials, and pain is an indication for foreign body removal. Radiography may be used to locate foreign bodies for removal, and ultrasonography can be helpful for localizing radiolucent foreign bodies. It is wise to set a time limit for exploration and to have a plan for further evaluation or referral. Injuries at high risk of infection include organic foreign bodies or dirty wounds. These should be treated with plain water irrigation and complete removal of retained fragments. In most cases, antibiotic prophylaxis is not indicated. If a patient presents with an infected wound, the possibility of a retained foreign body should be considered. Tetanus prophylaxis is necessary if there is no knowledge or documentation of tetanus immunization within 10 years, including tetanus immune globulin for the person with a dirty wound whose history of tetanus toxoid doses is unknown or incomplete. (Am Fam Physician 2007;76:683-8. Copyright © 2007 American Academy of Family Physicians.) oreign bodies may be retained in Investigating for Possible Foreign Body the body through many mechanisms, Patients may not be aware of retained mate- including ingestion, placement in rial, but if there is sensation of a foreign bodily orifices, and surgical errors. body, it is important to explore the wound. F This article is limited to objects that have Removal is easier if wounds are examined penetrated the skin. Puncture or impale- within 24 hours because the entry wound is ment injuries are common. In the United visible and open. Older injuries have inflam- States in 1999, there were 8.2 million emer- mation, induration, scarring, and/or gran- gency department visits for open wounds.1 ulated tissue, making it more difficult to Retained foreign bodies are not common. localize the foreign body. The risk of infec- The authors of one study involving patients tion increases with time until the wound is injured by broken glass found retained glass fully healed. in 15 percent of wounds.2 The risk of punc- The mechanism of injury is important in ture wounds and retained foreign bodies evaluating for foreign bodies. Bite injuries increases in warmer seasons or climates may include teeth, and punches to the face because of bare skin and outdoor recreation. may include tooth fragments in the punch- Persons who work in occupations such as ing hand. Broken objects causing wounds carpentry and the garment industry are at may leave embedded fragments. Wounds increased risk of impalement with nails or from nails or other sharp objects puncturing pins. These injuries are more common in the foot through shoes or socks may include children or adults with mental or physical remnants of leather, cloth, or rubber.4 impairment, which may result in behavior or The composition of the foreign body will lack of control that increases risk. influence evaluation and removal. Metal Although these injuries may seem minor, objects in soft tissue pose a lower risk of wounds with neglected foreign bodies are a infection than organic matter. Inert metal common cause of malpractice claims.3 Any foreign bodies may not have to be removed, wound that penetrates the skin should be because removal might cause more trauma evaluated to determine if exploration for for- than simply leaving them in place. The deci- eign bodies is needed. An accurate history of sion to remove a foreign body is also based the mechanism of injury and description of on symptoms or risk of complications. If a the probable object can help localize the prob- foreign body is producing pain, it should be lem and determine the need for removal. removed. Downloaded from the American Family Physician Web site at www.aafp.org/afp. Copyright © 2007 American Academy of Family Physicians. For the private, noncommercial use of one individual user of the Web site. All other rights reserved. Contact [email protected] for copyright questions and/or permission requests. Foreign Bodies in the Skin negative predictive value was high, 57 per- SORT: KEY RECOMMENDATIONS FOR PRACTICE cent of retained glass foreign bodies would 2 Evidence have been missed without radiography. Clinical recommendation rating References In patients with sensation of foreign body, superficial wounds that have been adequately Radiography should be used to evaluate B 5 explored do not require radiography. Plain deep wounds. films can be clinically beneficial in locating Ultrasonography should be used to localize B 7 radiolucent foreign bodies. glass foreign bodies in deep wounds with 5 Topical 4% liposomal lidocaine should be A 10 or without exploration. In patients without used for wound exploration in children. sensation, the history can guide the decision Foreign body wounds should be cleaned with A 14, 15 for further investigation. All glass is radi- tap water. opaque; however, there is limited ability for Antiseptic solutions should not be used for A 16 radiography to detect glass fragments smaller cleansing foreign body wounds because than 2 mm.2 Glass is inert and can be left in they slow healing. place if it is difficult to locate or remove. Antibiotics should be considered for human A 19 bites and bites on the hand. OTHER A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited- Pencil lead or graphite foreign bodies can quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual result in pigment tattooing and should be practice, expert opinion, or case series. For information about the SORT evidence removed. Metallic foreign bodies such as rating system, see page 612 or http://www.aafp.org/afpsort.xml. bullets or BBs may be removed without difficulty if superficial and distant from ten- dons, nerves, or blood vessels. When removal Types of Foreign Bodies might cause damage, metallic foreign bodies can be left in SPLINTERS place unless symptoms occur or infection is present. Splinters are commonly from wood, thorns, or spines from plants but also may be plastic or glass. Wood and Evaluation and Localization vegetative material must be removed from wounds Penetrating wounds can damage nerves or blood vessels. because they are associated with increased inflammation Evaluating patient sensation and circulation is essential. and risk of infection. Larger or buried splinters can result Superficial foreign bodies can sometimes be palpated or in difficulty removing the entire foreign body or local- visualized. Deeper foreign bodies may require additional izing it for removal. methods to localize. Palpation with a gloved finger should be avoided because of the risk of puncturing the glove FISHHOOKS and finger and being exposed to blood-borne diseases. Fishhooks caught in the skin are problematic because Imaging is not necessary if the foreign body is ade- of the barbs that are intended to keep fish on the hook. quately visible for removal or if it does not require Fishhooks have a straight shank and a curved belly with removal. For wounds that require imaging, appropriate a barbed point at the end. Some fishhooks have multiple modalities include radiography, computed tomography barbs. Others have multiple hooks, and it is necessary to (CT), and ultrasonography, depending on the size and cut off the other hooks for safe removal. Most fishhook type of foreign body. Underpenetrated plain radiography injuries occur in the hand, face or scalp, upper extremity, is the most economic and available method for viewing or foot. Fishhooks in the eyelid or eye require immediate radiopaque foreign bodies, including metal, bone, teeth, ophthalmologic referral. pencil graphite, certain plastics, glass, gravel, stone, some fish spines, wood, and aluminum.4 Although CT GLASS is more sensitive than radiography, the increased cost Patients with glass embedded in a wound are more likely limits CT to foreign bodies that are not visible on radi- to report the sensation of foreign bodies. One study ography and pose a risk of infection or joint injury.6 found that patient sensation was more likely for wounds Ultrasonography is widely available and helpful in with retained glass than for those without glass. The posi- finding wooden or radiolucent foreign bodies.7 Detec- tive predictive value of patient sensation was 31 percent; tion of foreign bodies with ultrasonography has a negative predictive value was 89 percent. Although the sensitivity of 50 to 90 percent and a specificity of 70 to 684 American Family Physician www.aafp.org/afp Volume 76, Number 5 ◆ September 1, 2007 Foreign Bodies in the Skin 97 percent for gravel, metal, cactus spines, wood, and plastic.4 In one study, ultrasonography localized 19 of 21 Table 1. Imaging Modalities for Localizing foreign bodies not found on radiography.7 Ultrasonogra- Various Types of Foreign Bodies in Skin phy can help determine the depth, size, and shape of the and Subcutaneous Tissue foreign body and its relationship to anatomic structures such as bones, tendons, blood vessels, or joints. Computed tomography Many foreign bodies are surrounded by a hypoecho- Reserve for failed exploration or infection genic area representing inflammation.8 Localizing some Radiography foreign bodies can be easier with multiple views, metal- Bone lic markers, or needles inserted close to the foreign body. Fish spines (some) Table 1 describes appropriate imaging modalities for Glass various types of foreign bodies.4,6-8 Gravel/stone Metal/aluminum Removal Techniques Pencil graphite Being adequately prepared for the removal of foreign Plastic (some) bodies increases success rates and avoids complications. Teeth Wound exploration is aided by optimal lighting, magni- Wood (e.g., splinters, cactus spines, thorns) fication, and adequate hemostasis. The wound and gloves Ultrasonography should be cleansed before removal is attempted.