Doctor Sussamn's Blog
Wednesday, September 12, 2018
Soft Tissue Foreign Body Removal Technique Using Portable Ultrasonography Karolina Paziana, MD; J. Matthew Fields, MD; Masashi Rotte, MD; Arthur Au, MD; Bon Ku, MD, MPP From Jefferson Medical College (Dr Paziana) and the Department of Emergency Medicine, Thomas Jefferson University, Philadelphia, PA (Drs Fields, Rotte, Au, and Ku). Retained foreign objects account for as much as 2% of soft tissue injuries sustained in the wilderness. Subcutaneously embedded fragments are often missed during the initial medical evaluation and may result in morbidity secondary to delayed removal. Although the utility of ultrasonography in the emergency department for the detection of retained objects is established, the potential use of point-of-care ultrasound to aid with foreign body removal in the field has not been well described. We present 2 case reports that demonstrate the value of ultrasonography in detecting and successfully removing foreign bodies sustained in the wilderness, and outline a procedural technique that minimizes morbidity and uses equipment available in wilderness medical field kits. We propose that with the advent of portable and handheld ultrasound units, foreign body removal in the field has become feasible and may decrease the morbidity of soft tissue injuries, particularly in austere and wilderness environments with limited access to immediate medical care. Key words: ultrasound, foreign body, removal, radiolucent Introduction The medical literature concerning foreign body related morbidity is limited, but the available data suggest that persons participating in wilderness activities are predisposed to a high frequency of soft tissue injuries. In fact, retained foreign objects are estimated to account for as much as 2% of wilderness sustained soft tissue injuries.1 The inability to promptly identify and remove such foreign bodies may result in patient morbidity by way of pain, infection, and inflammation, and potentially increase the financial burden to both the patient and the hospital owing to multiple physician visits and, in extreme cases, exploratory surgery.2 Although fragments of metal or glass may be readily visualized using plain film radiography, wood, plastic, and thorns are radiolucent and may often remain undetected on initial medical evaluation unless the history and examination suggest the need for further imaging. Ultrasonography is superior to plain x-ray film in its ability to reliably identify radiolucent objects, and is increasingly being used as a diagnostic tool in the emergency department (ED) to rule out retained foreign bodies in patients presenting with soft tissue injuries.3,4 Now, with the advent of portable and handheld machines, ultrasonography has the potential to be used in austere environments to offer on-site management for foreign body removal and reduce subsequent complications when access to medical services is either limited or delayed. The following cases underscore the value of ultrasonography in detecting retained foreign objects commonly sustained in the wilderness, particularly in patients with a suggestive history or physical examination with negative radiographic imaging. Additionally, we present our technique for ultrasound-assisted removal that uses equipment available in medical field kits commonly taken on wilderness expeditions or stored in medical camps, and suggest the potential value of carrying portable, lightweight sonographic devices along with medical equipment when navigating austere environments. Case 1 A 25-year-old woman presented to the ED complaining of worsening left knee pain with movement. She attributed the onset of pain to 2 weeks earlier, when she had Corresponding author: Bon Ku, MD, Thomas Jefferson University Hospital, 1020 Sansom Street, Suite 239, Philadelphia, PA 19107 (e-mail: email@example.com). WILDERNESS & ENVIRONMENTAL MEDICINE, 23, 343–348 (2012) been running on a trail in the woods and brushed against some bushes. She described the pain as sharp and stabbing, but could not locate an entrance wound. She presented to a health care provider who did not suspect a foreign body, but rather a muscle strain. The pain continued to worsen, however, causing her to present to the ED for further evaluation. A radiograph of the knee was negative for a foreign body (Figure 1A). Physical examination revealed no deformity, tenderness, or warmth to the knee, and full range of motion was retained. The patient expressed significant pain with knee flexion and extension. A point-of-care ultrasound scan was performed and revealed 2 foreign bodies in the medial aspect of the left knee, approximately 30 mm and 25 mm in length (Figure 1B). Both were removed using the technique outlined below (Figure 2). The patient was followed up after 7 days for suture removal, with no complications. Case 2 A 32-year-old man presented to the ED 2 days after sustaining what he suspected to be a splinter while cutting down a tree. He had felt a sharp pain in the hypothenar region of his left hand but could not visualize or palpate a foreign body. Over the following days, his palm became erythematous and painful, prompting him to seek medical attention. On examination, the patient was afebrile but had a warm, fluctuant area over the left palm. Plain film x-ray was negative for foreign body (Figure 3A). The region was lanced, with expression of purulent fluid. Given the history and the quantity of pus expressed, there was concern for a possible retained foreign body. A point-of-care ultrasound scan was performed and revealed a linear foreign body approximately 23 mm Figure 1. (A) Plain radiograph of left knee, negative for foreign body. (B) Ultrasonographic image of foreign body (arrow). Figure 2. Successful removal of thorns.
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