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Foreign Bodies of the Skin

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Foreign Bodies of the Skin, Skin Foreign Body, Foreign Body in Skin Wound, Skin Splinter, Foreign Body Removal, Splinter Removal, Retained Foreign Body, Removal of Foreign Body from Soft Tissue, Removal of Foreign Body from Skin, Embedded Splinter, Ultrasound of Retained Skin Foreign Body, Ultrasound Guided Skin Foreign Body Removal, Retained Skin Needle Fragment

  • See Also
  • History
  1. Mechanism of Injury
    1. Bite injuries
      1. See Human Bite or Animal Bite
      2. Consider retained tooth fragments and infection risk
    2. Broken objects
      1. Risk of retained and embedded fragments
    3. Sharp objects penetrating shoes, gloves or clothing
      1. See Puncture Wound
      2. Risk of retained cloth, leather or Rubber
  2. Foreign Body Types
    1. Metal
      1. Retained needles occur with IV Drug Abuse, Subcutaneous Injections (e.g. Insulin, Lovenox), Acupuncture
        1. Of the more than 6 Million who abuse IV Drugs in U.S., 20% report having broken a needle in skin
      2. Easiest to identify on Xray
      3. Lower risk of infection with Retained Foreign Body
      4. Removal may not be needed with small asymptomatic inert metal objects
    2. Glass
      1. All glass is radiopaque, but <2 mm fragments are missed on XRay
      2. Glass fragments cause the most foreign body sensations
      3. Removal may not be needed with small asymptomatic glass that is difficult to find
    3. Pencil leads or graphite
      1. Should be removed as much as possible due to secondary Tattooing
    4. Wood or vegetative material
      1. Must be removed due to infection and inflammation risk
    5. Fishhooks
      1. See Fishhook Removal
  • Exam
  1. Evaluate circulation, sensation and motor function before and after every intervention
  2. Exercise caution in palpating splinter - risk of skin puncture to examiner
  3. Evaluate for secondary infection (e.g. Skin Abscess, Cellulitis)
  • Symptoms
  1. Sensation of foreign body (variably present)
    1. If present, warrants wound exploration within first 24 hours
  • Imaging
  • XRay or CT localization of Soft Tissue Foreign body
  1. General
    1. Tape marker over or near entry wound
  2. Underpenetrated XRay: First-line study in most cases
    1. Metal or aluminum (99% of objects are radiopaque)
    2. Glass
    3. Plastic
    4. Pencil graphite
    5. Teeth
    6. Gravel or stone
    7. Wood
    8. Fish spines
  3. CT Scan
    1. Efficacy
      1. Significantly more sensitive than XRay
    2. Disadvantages
      1. Significantly more expensive than XRay
      2. CT-associated Radiation Exposure
    3. Indications
      1. XRay does not show foreign body and
      2. Retained Foreign Body risks infection or joint injury
  • Imaging
  • Soft Tissue Ultrasound localization of Soft Tissue Foreign Body
  1. Advantages
    1. Bedside Ultrasound in emergency department
  2. Efficacy: Identifying wood or radiolucent objects
    1. Test Sensitivity >50%
    2. Test Specificity >70%
  3. Objects identified (will appear bright white on Ultrasound)
    1. Gravel
    2. Glass
    3. Metal
    4. Cactus spines
    5. Wood
    6. Plastic
  4. Technique pearls
    1. Use high frequency linear probe
    2. Keep probe perpendicular to the skin surface
    3. Rotate the Ultrasound probe until best visualized (parallel to most superficial part of foreign body)
    4. Mark skin incision site, parallel to the underlying foreign body
    5. Inject local anesthetic (e.g. Lidocaine) along the marked path
    6. Make an incision long enough to allow a hemostat to enter and open enough to grasp object
  5. Other adjunctive measures
    1. Consider performing in a water bath to allow for a stand-off for superficial structure identification
    2. Under Ultrasound guidance, insert a sterile needle directed toward a retained metal foreign body
      1. Advance the needle until foreign body is contacted
      2. Further anesthetize the anticipated tract
      3. Dissect down to the needle tip and adjacent foreign body
  • Indications
  • Foreign Body Removal
  1. Infection (e.g. Skin Abscess, Cellulitis, Bacteremia)
  2. Acutely Retained Foreign Body with pain
  3. Retained Foreign Body well localized on imaging
  4. Fragment confined to skin or soft tissue
  • Contraindications
  • Foreign Body Removal
  1. Noncompliant Patient
  2. Foreign body within or near neurovascular structures (e.g. intravascular retained needle)
  3. Chronically Retained Foreign Body
  4. Imaging not well localized on imaging
  • Complications
  • Foreign Body Removal
  1. Failed Foreign Body Removal
  2. Embedding foreign body deeper into soft tissue or closer to neurovascular structures
  3. Larger surgical wound than original puncture (all cases)
  • Management
  • General
  1. Tetanus prophylaxis
  2. Irrigate wound with saline at pressures of 5 to 8 psi
    1. Do not add betadine, hydrogen peroxide or antibiotics
      1. Toxic to the tissues
    2. Do not inject irrigant into Puncture Wounds
      1. Risk of driving contaminant in deeper
  3. Prophylactic antibiotics usually not needed
    1. Antibiotic prophylaxis used in past
    2. Indications to start antibiotics
      1. Bite injury (e.g. Human Bite, Dog Bite, Cat Bite)
      2. Consider in contaminated wound, risk of joint or bone infection, organic material
      3. Retained Foreign Body
  • Management
  • Removal of superficial horizontal splinters
  1. Forceps (e.g. needle nose Splinter Removal forceps)
    1. Risk of Retained Foreign Body
  2. Incision Technique
    1. Prepare overlying skin with Betadine or Hibiclens
    2. Local Anesthesia
      1. Required only for incision technique below
      2. Digital Block with 1% Lidocaine on fingers
      3. Elsewhere with 1% Lidocaine with Epinephrine
    3. Option 1: Incise skin with #15 blade
      1. Incision directly over long access of splinter
      2. Remove splinter when completely exposed
    4. Option 2: De-roof splinter with 18 gauge needle
      1. Gently stroke skin overlying splinter to unroof
      2. Splinter then lifted out with needle tip
    5. Irrigate lesion with Normal Saline after removal
      1. Do not flush via needle or catheter in tract
  • Management
  • Removal Vertical Splinters
  1. Prepare overlying skin with Betadine or Hibiclens
  2. Local Anesthesia
    1. Digital Block with 1% Lidocaine on fingers
    2. Elsewhere with 1% Lidocaine with Epinephrine
  3. Eliptical incision over end of splinter
  4. Deeper incisions made to either side of splinter
  5. Remove splinter when exposed
  6. Irrigate lesion with Normal Saline after removal
    1. Do not flush via needle or catheter in tract
  • Management
  • Removal Subungual Splinter
  1. Prepare overlying skin with Betadine or Hibiclens
  2. Digital Block with 1% Lidocaine on fingers
    1. Required only for Option 1 (Nail Avulsion)
  3. Option 1: Nail plate avulsed
    1. Remove V-Section of nail overlying splinter
    2. See Toenail Removal for technique
  4. Option 2: Nail plate shaving with #15 blade or cautery (Nail Trephination over foreign body)
    1. Shave surface gently with blade overlying splinter
    2. Creates a hole in nail over splinter
  5. Remove splinter when exposed
  6. Irrigate lesion with Normal Saline after removal
  • Precautions
  • Splinters with difficult isolation
  1. Retained Foreign Body is a common cause of Malpractice
  2. Early Foreign Body Removal within first 24 hours is important
    1. Open wounds are easier to explore
    2. Old wounds with scarring and inflammation impede Foreign Body Removal
    3. Infection risk increases with duration of foreign body presense
  3. Limit "digging" for difficult splinter to 20-30 minutes
    1. Stop and refer if not found within that time
  4. Blunt Dissection with care at wound site
    1. Controlled, sterile exploration with hemostasis
    2. Do not blindly dissect wound with hemostats
  5. Consider imaging for localization (see above)
  • Complications
  • Retained Foreign Body in general
  1. Local inflammation
    1. Highest risk with vegetation (e.g. thorns, wood)
  2. Local infection (1-12% risk of Skin Abscess or Cellulitis)
    1. Single most important preventive step is Foreign Body Removal
    2. Antecubital fossa is a common site of IV Drug Abuse and complications from broken needles
      1. Avoid exploring antecubital abscess before imaging to evaluate for Retained Foreign Body (needle)
  3. Serious infectious complications
    1. Compartment Syndrome
    2. Necrotizing Fasciitis
    3. Septic Joint
    4. Osteomyelitis
  4. Granuloma formation
  5. Toxic reaction
  • Complications
  • Retained Intravascular Needle Fragments (Broken Needles)
  1. See Retained Foreign Body complications (as above)
  2. Deep Vein Thrombosis
  3. Fragment Embolization
    1. Pneumonia
    2. Empyema
    3. Endocarditis
    4. Pericarditis
  • References
  1. Chapman (2020) Crit Dec Emerg Med 34(2):12-3
  2. Mortiere (1996) Primary Wound Management, p. 70
  3. Chan (2003) Am Fam Physician 67(12):2557-62 [PubMed]
  4. Halaas (2007) Am Fam Physician 76(5): 683-8 [PubMed]