Retained Foreign Body

Three weeks earlier, a 65-year-old man had sustained lacerations on the dorsum of his right wrist and his right middle finger from a shattered glass door. He had self-treated the injuries. The laceration on his wrist healed, but the one on his finger became increasingly painful and swollen. The patient denied fever or chills. He had had a single kidney since birth; his history was otherwise unremarkable. Vital signs and physical findings were normal, with the exception of significant edema, erythema, and warmth distal to the wrist of the right hand. A small abscess with local drainage was noted on the third digit between the interphalangeal and metacarpal joints (A ). Active motor function in the hand was limited. Passive range of motion was intact on flexor and extensor testing of all digits. Sensory and motor function was completely intact. Capillary refill time was less than 2 seconds. Radial and ulnar pulses were palpable. A radiograph of the right hand revealed a retained foreign body in the soft tissues of the third finger (B ). There was no bone or joint involvement. Because of the limited active range of motion of the patient’s finger and anticipated need for surgical exploration and debridement, an orthopedic surgeon was consulted. Intravenous cefazolin (1 g) was administered. The wound was explored under local anesthesia, and a 2-cm piece of glass was removed (C ).  David Farcy, MD, Hillary Cohen, MD, Hashibul Hannan, MD, and John Marshall, MD, of Brooklyn, NY, write that puncture wounds usually involve the hands and feet and are typically accidental.1  Objects that cause puncture wounds tend to penetrate deep tissue and can injure nearby structures.  Plain radiography is nearly 100% sensitive in detecting pieces of glass that are larger than 2 mm, and glass does not need to be lead-based to be visible.2  Ultrasonography using a linear probe with a frequency between 7.5 and 10 MHz can also detect glass. Often, foreign bodies are hyperechoic and demonstrate useful sonographic artifacts, such as shadowing or reverberation (also known as a “comet tail” artifact).3 Bacterial infection is the most common complication. The most frequently isolated organism is Staphylococcus aureus, followed by other Staphylococcus species and Streptococcus species. Puncture wounds of the sole are generally infected with Pseudomonas aeruginosa, which is thought to colonize the plastic material of the shoe.4  Infection that arises at a later time than expected and failure of antibiotic therapy may suggest a retained foreign body. Check the tetanus vaccination status of patients with puncture wounds, and give prophylaxis as needed. The longer the delay from the time of injury to the time of treatment, the greater the risk of infection. Patients with diabetes mellitus or peripheral vascular disease and other immunocompromised patients are at increased risk for infection. Wound irrigation to remove the foreign object and decrease bacterial contamination is essential. Large-volume irrigation improves wound decontamination. High-pressure irrigation has been shown to remove more bacteria and foreign material and to lower the rate of wound infection.5  Antibiotic solution for irrigation has not been shown to be effective and is not recommended.5 Infections associated with a retained foreign body are generally antibiotic-resistant. They often resolve spontaneously once the foreign body is removed.6  Although the practice is controversial, an antibiotic can be prescribed within 12 hours of the injury. Amoxicillin/clavulanate and first-generation cephalosporins provide good coverage of most Staphylococcus and Streptococcus species. This patient was discharged on a regimen of oral cephalexin (500 mg/d for 10 days); follow-up was arranged in the orthopedic clinic. A retained foreign object is easy to miss. A careful history, high index of suspicion, and early imaging can help avoid this potential complication. REFERENCES: 1. Gron P, Andersen K, Vraa A. Detection of glass foreign bodies by radiography. Injury. 1986;17:404-406. 2. Felman AH, Fisher MS. The radiographic detection of glass in soft tissue. Radiology. 1969;92:1529-1531. 3. Tibbles CD, Porcaro W. Procedural applications of ultrasound. Emerg Med Clin North Am. 2004;22:797-815. 4. Eckerline C. Puncture wounds and bites. In: Tintinalli JE. A Comprehensive Study Guide in Emergency Medicine. 5th ed. Dallas: American College of Emergency Physicians; 2000:331-335. 5. Anglen JO. Wound irrigation in musculoskeletal injury. J Am Acad Orthop Surg. 2001;9:219-226. 6. Capellan O, Hollander JE. Management of lacerations in the emergency department. Emerg Med Clin North Am. 2003;21:205-231.