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Foreign Bodies of the SkinAka: Foreign Body Removal, Splinter Removal, Retained Foreign Body

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. Easiest to identify on Xray
    2. Lower risk of infection with retained foreign body
    3. 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
Symptoms
1. Sensation of foreign body (variably present)
  1. If present, warrants wound exploration within first 24 hours
Imaging: Foreign body localization
1. General
  1. Tape marker over or near entry wound
2. Imaging modalities
  1. Underpenetrated XRay: First-line study in most cases
    1. Metal or aluminum
    2. Glass
    3. Plastic
    4. Pencil graphite
    5. Teeth
    6. Gravel or stone
    7. Wood
    8. Fish spines
  2. CT Scan
    1. Significantly more sensitive than XRay, but significantly more expensive
    2. Indications
      1. XRay does not show foreign body and
      2. Retained foreign body risks infection or joint injury
  3. Ultrasound
    1. Efficacy: Identifying wood or radiolucent objects
      1. Test Sensitivity >50%
      2. Test Specificity >70%
    2. Objects identified
      1. Gravel
      2. Glass
      3. Metal
      4. Cactus spines
      5. Wood
      6. Plastic
Complications: Retained foreign body
1. Local inflammation
  1. Highest risk with vegetation (e.g. thorns, wood)
2. Local infection (1-12% risk)
  1. Single most important preventive step is foreign body removal
3. Granuloma formation
4. Toxic reaction
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
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
  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)
References
1. Mortiere (1996) Primary Wound Management, p. 70
2. Chan (2003) Am Fam Physician 67(12):2557
3. Halaas (2007) Am Fam Physician 76(5):683

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Foreign Bodies of the SkinAka: Foreign Body Removal, Splinter Removal, Retained Foreign Body

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