Emergency providers are often called upon to evaluate acute wounds that are at risk for embedded foreign bodies. Assessment of older wounds may also be complicated by retained foreign material that was initially unrecognized and can impact the healing process and risk of subsequent infection. Careful evaluation of wounds, radiographic imaging when indicated, and local exploration allow identification of most foreign bodies. Once identified, many foreign bodies can be removed in the emergency department, although some may be left in place or referred to appropriate specialists for delayed removal.
While only a small percentage of lacerations and puncture wounds contain foreign bodies, carefully assess all injuries to evaluate for potentially unrecognized retained material. The mechanism of injury, composition and shape of the wounding object, and the shape and location of the wound are all factors to consider. Objects that have broken, shattered, or splintered at the time of injury may increase the risk of an embedded foreign body. Brittle materials such as thorns, spikes, or branches may penetrate deeply into tissue before breaking. Wood splinters often fragment when pulled from a puncture wound.
Adult patients who complain of a foreign body sensation in an acute wound more than doubles the likelihood of one being present. Wounds that have healed but continue to be the source of sharp pain with movement or pressure over the site may represent a retained foreign object. Other potential signs of an unrecognized foreign body may include poor wound healing, recurrent infections, or the development of soft tissue masses.
Most foreign bodies can be identified through deliberate and careful exploration of wounds determined to be at risk. Use adequate lighting, appropriate anesthesia, and hemostasis techniques to optimize wound evaluation. Visually inspect all recesses of a wound, when possible, recognizing that wounds deeper than 5 mm or where the full depth cannot be visualized have a higher association with foreign bodies. Consider extending the wound margins with a scalpel to permit a more complete exploration when appropriate. Blind and gentle probing with a closed hemostat can be an effective method to identify some foreign bodies, such as glass fragments, when direct visualization is not possible.
DIAGNOSIS AND DIFFERENTIAL
When a foreign body is suspected but not identified and removed during visual inspection, consider radiographic imaging for further evaluation. Most foreign bodies can be seen on plain radiographs, although CT scan, ultrasound, or MRI may be indicated in some circumstances (Table 14-1). Use an underpenetrated soft tissue plain radiography technique or adjust the contrast and brightness when using a digital system to increase the likelihood of identifying a foreign body. CT scan is capable of detecting more types of materials than plain film radiography, and may be useful for thorns, spines, wood splinters, or plastic foreign bodies. Ultrasound can be useful at the ...