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Wounds with retained foreign bodies are a frequent presenting complaint to Emergency Departments. Up to 38 percent of embedded objects are missed on the initial assessment.1 Identification and removal of debris and foreign bodies promotes optimal healing of traumatic wounds. The presence of an unrecognized foreign body can lead to complications that include infection, pain, loss of function, joint injury, tenosynovitis, tendon rupture, and osteomyelitis.2–5 Patients presenting with chronic, recurrent, or delayed skin infections should be assessed for the presence of an unrecognized foreign body. Failure to diagnose and treat a foreign body is a common cause of litigation against Emergency Physicians. The presence of a foreign body may not be obvious. A high index of suspicion and careful methodical examination, including appropriate imaging, must be undertaken to identify a foreign body.

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It is important to be familiar with the characteristics of different types of foreign bodies and the interactions they may have with a host patient. This information is crucial in determining the urgency or necessity of removal (not all implanted objects require removal), the appropriate imaging techniques, the approach to removal, and whether specialty referral is required. The removal of foreign bodies from subcutaneous tissue can be a frustrating and time-consuming endeavor when it is ill conceived. The successful removal of a foreign body requires a directed history and physical examination, appropriate imaging, adequate light, anesthesia, exposure, hemostasis, patient cooperation, an uninterrupted time period for attempted removal, appropriate wound care, and assured post-procedural follow-up.

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Only a small percentage of wounds actually contain concealed foreign bodies.6 The mechanism of injury may give some idea of the likelihood of a retained object.1 Crush wounds and puncture wounds, especially those involving the sole of the foot, as well as wounds deeper than 5 mm involving adipose tissue are associated with a higher incidence of foreign bodies that are often difficult to find.6 Wounds caused by objects that shatter, splinter, or break in the process of causing injury have a higher risk of having a retained foreign body.7 Lip or facial lacerations associated with dental fractures must be explored for pieces of teeth. Thorns, spines, or slivers tend to penetrate deeply and break. Broken-off needles are common foreign bodies in injection drug users. Objects greater than 4.5 mm in diameter that penetrate the skin may push fragments of epidermis deep into the wound producing an epidermal inclusion cyst, which can act as a foreign body.8

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Depending upon the type of material retained and the physical form of the foreign object, excess inflammation may result. This can delay healing or destroy surrounding soft tissues. Retained organic foreign bodies trigger the most severe inflammatory reactions and can lead to chronic granulomatous reactions, periosteal reactions, osteolytic lesions, or severe infections such as fatal necrotizing fasciitis.8–10 The presence of soil in wounds markedly lowers the concentration of bacteria required to cause an infection by its interaction ...

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