Inert (Nonreactive) Objects

Inert objects include bullets, needles, and other metallic items. Although they do not provoke inflammation, these objects can cause chronic pain and discomfort, especially in weight-bearing areas or near joints. Metals that oxidize (i.e., rust) can cause mild to moderate tissue reaction. The clinical decision to remove an inert object has to be weighed against the potential damage that could be created during a search for the object. Inert objects can be left in place if they are inaccessible and will not cause tissue damage or functional deficit. If left alone, noncritical inert foreign bodies encapsulate within soft tissue and cause no further problem.

A question sometimes arises concerning lead foreign bodies, usually bullets, and the risk of lead absorption and toxicity. When compared with controls, patients with extraarticular retained missiles (lead bullets) show a rise in lead levels over time, but the vast majority (96%) of level increases were shown not to be clinically significant. In a study of patients with retained bullets, lead levels averaged 17 μg/dL compared with 7μg/dL in the control patients ( P < .002). Levels greater than 10 μg/dL are considered toxic. Clinical signs of toxicity are uncommon, however. Symptoms, such as fatigue, headache, and nausea, can be low grade and vague. If toxicity is suspected, patients are referred for lead level testing and evaluation.

Although glass is considered inert, glass foreign bodies are often symptomatic. If the glass is accessible, removal is recommended except for small, insignificant fragments. Pencil “lead” (i.e., graphite) is inert but can cause tattooing. It also can be accompanied by wood fragments during injury. For these reasons, even though it is inert, graphite should be removed from the injury site.

Organic (Reactive) Objects

Objects that are not inert—wood, bone, soil, stones, rubber, and other organic materials such as thorns—must be removed in their entirety. These materials can cause a variety of bacterial and fungal infections. Synovitis from joint penetration, periosteal reactions, foreign-body granulomas, draining fistulas, and pseudotumors of the soft tissue all have been reported with noninert foreign objects. Retained wood objects have been reported to cause chronic inflammation, drainage, and pain for 7 years after penetration. A missed diagnosis or failure to remove all fragments of a noninert object can lead to prolonged disability and patient discomfort.

Clinical Evaluation

When a foreign object penetrates the skin, patients cannot reliably report its presence. In glass wounds, reliance on the patient’s history alone would lead to 50% missed fragments. For cases in which no foreign body is reported, certain clinical settings carry a higher risk for one being present. Any injury with glass should raise the suspicion of a retained fragment. For glass injuries, the head and foot are more likely to have retained fragments. For lip or perioral injuries in which there is traumatic loss of dentition, a tooth fragment might be embedded in the soft tissue. Injuries to the feet or hands with needles, nails, or splinters should be suspected of retention if the patient cannot account for the entirety of the injuring object. If the suspicion is strong, the caregiver is obligated to perform a diagnostic evaluation and local exploration to rule in or rule out the possibility of a retained foreign object.

Before anesthetic is administered, gently running a gloved finger over the suspected foreign-body site can elicit in a patient the characteristic sensation. In the anesthetized wound, gently probing and drawing a closed hemostat in and through the wound can alert the operator to the presence of a wood, glass, or metallic foreign body. The hemostat transmits a distinct “grating” sensation. Probing can reveal the presence of an inert object or a wood splinter before it has been softened by the absorption of tissue fluids.

Imaging

Radiodense Objects

For objects that are located below the surface and out of direct sight, careful localization is necessary before proceeding with exploration. Radiodense objects can be localized by a variety of techniques using markers and radiographs. A simple technique recommended by the author is to bend a paper clip to form a flat plane with an extended arm. The extended arm is placed directly over the skin entry wound created by the foreign object, and the paper clip is secured with a small piece of tape ( Fig. 16-1 ). Two radiographs are taken exactly at an angle of 90 degrees to each other (anteroposterior and lateral views) using the plane of the clip as a geometric point of reference ( Figs. 16-2 and 16-3 ). In this manner, the location and the depth of the object relative to the extended arm of the paper clip can be determined. Magnification by this technique occurs, and the distance between the object and the clip on the radiograph is greater than the actual distance. After appropriate cleansing and the administering of an anesthetic, a small incision is made, and exploration is performed until the object can be removed. The radiographs are needed for reference in the care area during the removal.

Technique for placing a reconfigured paper clip with the extended arm of the clip directly over the entry point of a foreign-body penetration.

Direct anteroposterior view of the paper clip and foreign body.

Direct lateral view of the paper clip and foreign body. This type of radiograph and that in Figure 16-2 can be used to locate accurately the position of the foreign body relative to the extended arm of the clip by the anteroposterior view and the depth of the foreign body by the lateral view.

Nonradiodense Objects

If ultrasonography is not available to assist in removal, nonradiodense objects are best approached through a more generous incision and thorough exploration by direct visualization. Incisions permit débridement and removal of tissue that is embedded with foreign material. When the foreign body is located in the hand or the foot, the exsanguination tourniquet technique (see Chapter 9 ) is recommended. Even a small amount of bleeding can make visualization impossible.

Techniques for Removal

When attempts to remove foreign bodies are made by an emergency physician, removal was successful in 89% of cases. Consultation by surgical specialist occurred in 47 cases with a success rate of 65.6% of those cases.

The following steps are recommended for buried foreign bodies:

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  The first step is to decide whether a removal attempt should be made in the ED. Removal is likely to be successful if the object has been under the skin for less than 1 week, the object is visible, the entry wound is fresh, the object can be localized with an imaging procedure, the object is radiodense, or the object can be felt during probing. Success is less likely if the object is deep, if it has been present for several weeks or months (as is often the case with needles), if no entry point is present, if the object is nonradiodense, and if the object cannot be localized.

  
  
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  Ideally, foreign bodies seen in the ED are more easily removed elsewhere in bloodless conditions; however, most FBs are small and superficial enough to be located and removed.

  
  
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  After the decision is made to remove the FB, the area is cleaned with Betadine or chlorhexidine.

  
  
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  In order to prevent excessive swelling, anesthesia should be administered by nerve block if possible. Swelling of local anesthesia can make locating the FB more difficult. If no alternative is available, as little local anesthesia as possible should be used.

  
  
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  A no. 15 scalpel blade is used to make an incision over the entry point, parallel to the axis of the FB if it can be determined.

  
  
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  A small curved clamp can be used to explore the incision site for the FB. The clamp tip is gently “raked” through the site to feel steel against glass, wood, or metal to assist localization.

  
  
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  Once localized, the FB is grasped and removed. See the following text for an explanation of the removal of wood or organic objects.

  
  
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  After removal, the wound is irrigated and a dressing is applied. Incisions, except if they are large and gaping, should not be sutured.

Simple retrieval is not always possible, however. As a rule, if attempts at retrieval exceed 20 to 30 minutes, serious consideration should be given to terminating the procedure and obtaining consultation.

Protruding Objects

For objects that are partially protruding from the skin, the temptation to “grab and yank” must be resisted. If a wood splinter is pulled out injudiciously through a small, tight entry wound, small fragments can be stripped off the splinter and can be left behind to cause future difficulty. The technique illustrated in Figure 16-4 shows how a small incision is made in the finger parallel to the course and angle of the object. By creating an incision, the splinter can be removed without leaving behind smaller splinters. In addition, the wound can be copiously irrigated to decrease the level of bacterial contamination. These small incisions must not be closed with sutures. They should be left open to drain the site, if necessary, and to prevent the accumulation of purulence that might lead to the formation of an abscess.

Top, Technique for removing a small splinter from between the nail plate and the nail bed. A small wedge of nail has been removed to gain exposure to the protruding splinter. A small hemostat is used to extract the splinter gently. Bottom, Technique for removing a penetrating foreign body, a splinter, which is protruding from the skin. A small incision is made directly away from the entry point, parallel to the shaft of the foreign body. The splinter can be removed in its entirety without leaving smaller splinters.