A 20-year-old woman sustained a puncture wound to the sole of
her foot from a wooden splinter while walking barefoot on the hardwood
floor of her home. She removed the splinter that protruded from
her foot. She believed that she had pulled out the entire splinter,
but the pain persisted so she came to the ED next morning.
A small puncture wound in the region of the metatarsal heads
was cleaned superficially. No foreign body was visible or palpable
at the site of the puncture wound. There was tenderness but no swelling,
redness, or drainage from the wound. Radiographs were obtained and
reported as negative for a foreign body (Figure 1).
The patient was instructed to limit weight bearing, elevate the
foot, and to return to the ED if there was persistent or increasing
pain, swelling, redness, or fever.
- Do you agree with this management?
Failure to detect retained foreign bodies is a major pitfall
in wound management. In one series, 38% of foreign bodies
in hand wounds were missed on initial presentation (Anderson et
al. 1982). In a large series of ED malpractice litigation claims,
wound care cases accounted for 24% of malpractice claims,
and failure to detect or treat a foreign body accounted for 44% of
wound care litigation cases (Karcz et al. 1990).
for failure to detect a foreign body include
(1) incomplete or inadequate history of the injury; (2) misleading
history (e.g., the patient does not recall stepping on a needle);
(3) inadequate wound exploration; (4) failure to obtain radiographs;
or (5) radiolucency of the foreign body.
The diagnosis of radiolucent soft tissue
foreign bodies can be a vexing problem. Conventional radiography
has a limited ability to distinguish soft tissues and organic wound
contaminants such as wood, thorns, soil, and fabrics, which have
a high rate of infectious complications. (NB. The terms “radiolucent” and “radiopaque” do
not relate to the object itself but are only meaningful when an
object’s radiographic density is compared to that of its
Conventional radiography will,
in a small number of cases, demonstrate
a wood foreign body. Therefore, after adequate wound exploration,
some authors suggest that radiographs should be obtained when a
retained foreign body is suspected. This recommendation is supported
by one series of hand wounds in which 15% of wood foreign
bodies were visible on the radiographs (Anderson et al. 1982). When
the wood is dry, it has the radiographic density of air and might
therefore be detectable as a radiolucent foreign body. However, in
most studies, wood and other radiolucent foreign bodies were not
visible on ...