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Clinical Summary

All foreign bodies can become a nidus for infection; reasonable attempts should be made to remove them. Radiographic evaluation or ultrasound (see related item and chapter) may assist in locating foreign bodies not directly visualized. Foreign bodies are characterized as being either reactive (eg, organic materials such as wood, bone, and soil) or nonreactive (eg, glass and metal).

Management and Disposition

Patients are often unaware that a foreign body is present. A high level of clinical suspicion should accompany any injury pattern at risk for foreign-body penetration, such as lacerations caused by broken glass, perioral injuries with loss of dentition, and injuries involving needles, nails, or splinters.

Suspicion of a retained foreign body mandates local wound exploration and the consideration of radiographic or ultrasound evaluation. Most objects can be identified on plain radiographs. More specifically, approximately 90% of glass fragments greater than 2 mm in size can be identified using plain radiographs; fragments as small as 0.5 mm can be identified in 50% to 60% of cases. In situation where plain radiographs are poor, ultrasound may be considered.

FIGURE 18.6

Radiodensity of Common Foreign Bodies. The plain radiograph (A) demonstrates the radiodensity of common foreign bodies. Counterclockwise from top left: pebbles, paper clip fragment, wood splinter, hollow needle, light bulb glass, dark (“beer bottle”) glass, transparent glass, and automobile windshield glass. Note that, although faint, the wood splinter is visible on plain radiography. Ruler markings (B) for the photograph of the corresponding objects are in centimeters. (Photo contributor: Matthew D. Sztajnkrycer, MD, PhD.)

Due to their increased risk for delayed infection and poor wound healing, reactive material must be removed. Nonreactive objects, however, may be left in place if reasonable effort to remove them has been unsuccessful and no potential for harm to a vital structure exists. Glass, however, has the potential for significant irritation and a removal attempt should be pursued.

Pearls

  1. The base of the wound must be visualized as many foreign bodies hide there.

  2. Common foreign bodies retained in hand wounds are wood splinters, glass fragments, metallic objects, and needles.

  3. Missed retained foreign bodies are a common source of litigation.

FIGURE 18.7

Radiodensity of Common Foreign Bodies in Tissues. The paper clip, dark glass, and wood splinter (top to bottom) imaged in Fig. 18.6 were inserted into chicken legs and radiographs taken. The wood splinter is no longer clearly visible within the soft tissue. For purposes of foreign-body localization, a minimum of two radiographic views at 90 degrees to one another are obtained, and the site of the foreign-body entry clearly marked. (Photo contributor: Matthew D. Sztajnkrycer, MD, PhD.)

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