TY - JOUR
AU - USA, Marc E. Levsky, MC
AB - ABSTRACT A 16-year-old, dependant, female patient presented to the emergency department complaining of a sewing needle stuck in her right great toe. The needle was removed with real-time ultrasound guidance, with no complications. The use of ultrasonography for localization of foreign bodies is discussed. Case Presentation The 16-year-old, dependant, female patient presented to the emergency department complaining of a needle stuck in her right great toe. She had stepped on the sewing needle while walking on a carpet at home. She noted that the needle had broken into two pieces, leaving one piece on the floor and the other deeply embedded in her toe. The patient stated that she felt a laminating pain in her toe each time she stepped. Her vital signs were normal, and the physical examination was unremarkable except for tenderness to palpation on the plantar surface of the toe, with a 1-mm puncture wound on the medial surface of the toe. Radiographs confirmed the presence of a large metallic foreign body in the plantar soft tissue of the toe, under ≥ 1 cm of tissue in every direction. After discussion of the treatment alternatives with the patient and her family, the patient opted for an attempt at removal in the emergency department, because of the discomfort she felt with walking. The foreign body was localized in three planes by using a SonoSite Titan ultrasound machine and a L38/10-5 broadband linear-array transducer (SonoSite, Bothell, Washington) (Fig. 1). The toe was then prepared with povidone-iodine solution. Local anesthesia was achieved through digital block with 1% lidocaine. With real-time ultrasound visualization, an 18-gauge needle was introduced through the site of the patient's puncture wound. During this procedure, it was determined that the foreign body was no longer in line with the puncture wound, and the finder needle was removed. An 18-gauge needle was then inserted through a site ∼5 mm from the puncture wound site, chosen so that the trajectory of the finder needle would exactly match the lie of the foreign body. With this second pass, the finder needle was observed on ultrasound images to be touching the foreign body, and the foreign body could be felt through the needle. The finder needle was then removed. A fine-point, straight, hemostatic clamp from an otolaryngological surgery tray was then introduced through the second finder needle path, in line with the foreign body, and the jaws of the clamp were opened. The jaws were guided around the foreign body and closed on it under direct ultrasound visualization (Fig. 2). The foreign body was then removed with gentle traction (Figs. 1 and 3). Fig. 1 View largeDownload slide Titan linear ultrasound probe and foreign body. Fig. 1 View largeDownload slide Titan linear ultrasound probe and foreign body. Fig. 2 View largeDownload slide Ultrasound visualization of the clamp grasping the needle. Fig. 2 View largeDownload slide Ultrasound visualization of the clamp grasping the needle. Fig. 3 View largeDownload slide Removed foreign body. Fig. 3 View largeDownload slide Removed foreign body. The patient was given wound care instructions and close follow-up monitoring with her primary care manager. She was contacted via telephone 10 days after the procedure, and she stated that she had no further pain after the removal, and she noted no complications. Discussion Foreign bodies that are retained in wounds can create significant problems, including infection, chronic pain, and repeat visits, and can be a major source of medico-legal liability.1,2 Standard screening for suspected foreign bodies that are radiopaque consists of plain radiographs; however, ultrasonography is another option, because of its accessibility, speed and ease of use, and low cost. The use of ultrasonography for localization of foreign bodies is well documented in the literature,3 but its utility for detection of foreign bodies when a foreign body is not known to be present is controversial, and studies have differed widely regarding reported sensitivity and specificity.4,–8 Like all ultrasound procedures, the success of foreign body localization and removal is dependent on a number of factors, including anatomic location, foreign body material, and operator skill. In this case, several factors made the foreign body amenable to removal, even with its somewhat deep position under the skin. The relatively large metallic object was easy to visualize on ultrasound images, and its linear shape provided a convenient vector on which to probe for removal; this vector was precisely determined by using linear ultrasound imaging sequentially in three planes. The longitudinal plane was used for probing with the finder needle and subsequent removal with the clamp, because it allowed precise alignment of the finder needle, followed by real-time visualization of the jaws of the clamp as they grasped the foreign body. By keeping both the jaws of the clamp and the foreign body in the plane of the ultrasound beam during the entire procedure, precise localization was ensured. Although a number of ultrasound procedures for foreign body removal have been described in the literature,9,10 we found no previous reference to a method like ours for a subcutaneous foreign body. There a number of alternatives to the procedure we performed in this case. First, and most conservatively, would have been watchful waiting, with no specific attempt at removal. Our patient did not want to try this approach because she was experiencing pain with each step she took. The second, and more traditional, method would have been to widen the entrance wound in an attempt to probe and to remove the foreign body and/or to perform a tractotomy over its site. The latter of these procedures could have been assisted by ultrasound visualization of the foreign body. In our initial attempt at ultrasound localization, we determined that the foreign body had been significantly displaced from the vector of its original entry; therefore, any attempt to retrieve the foreign body through the puncture wound through which it entered would likely have failed. Military physicians can benefit from the use of ultrasonography in foreign body localization and removal, because soft tissue wounds with foreign bodies are a common problem, especially in deployed environments. Many forward units are now being equipped with ultrasound machines, making a technique like that described here feasible for deployed physicians. References 1. Gwynne A, Barber P, Tavener F A review of 105 negligence claims against accident and emergency departments. J Accid Emerg Med  1997; 14: 243– 5. Google Scholar CrossRef Search ADS PubMed  2. Manthey DE, Storrow AB, Milbourn JM, et al.   Ultrasound versus radiography in the detection of soft tissue foreign bodies. Ann Emerg Med  1996; 28: 7– 9. Google Scholar CrossRef Search ADS PubMed  3. Tibbles CD, Porcaro W Procedural applications of ultrasound. Emerg Med Clin North Am  2004; 22: 797– 815. Google Scholar CrossRef Search ADS PubMed  4. Orlinsky M, Knittel P, Feit T, et al.   The comparative accuracy of radiolucent foreign body detection using ultrasonography. Am J Emerg Med  2000; 18: 401– 3. Google Scholar CrossRef Search ADS PubMed  5. Rockett MS, Gentile SC, Gudas CJ, Brage ME, Zygmunt KH The use of ultrasonography for the detection of retained wooden foreign bodies in the foot. J Foot Ankle Surg  1995; 34: 478– 84. Google Scholar CrossRef Search ADS PubMed  6. Hill R, Conron R, Greissinger P, et al.   Ultrasound for the detection of foreign bodies in human tissue. Ann Emerg Med  1997; 29: 353– 6. Google Scholar CrossRef Search ADS PubMed  7. Graham DD Jr Ultrasound in the emergency department: detection of wooden foreign bodies in the soft tissues. J Emerg Med  2002; 22: 75– 9. Google Scholar CrossRef Search ADS PubMed  8. Friedman DI, Forti RJ, Wall SP, Crain EF The utility of bedside ultrasound and patient perception in detecting soft tissue foreign bodies in children. Pediatr Emerg Care  2005; 21: 487– 92. Google Scholar CrossRef Search ADS PubMed  9. Leung A, Patton A, Navoy J, Cummings RJ Intraoperative sonography-guided removal of radiolucent foreign bodies. J Pediatr Orthop  1998; 18: 259– 61. Google Scholar PubMed  10. Nelson AL, Sinow RM Real-time ultrasonographically guided removal of nonpalpable and intramuscular Norplant capsules. Am J Obstet Gynecol  1998; 178: 1185– 93. Google Scholar CrossRef Search ADS PubMed  Reprint & Copyright © Association of Military Surgeons of the U.S.
TI - A Procedure for Soft Tissue Foreign Body Removal under Real-Time Ultrasound Guidance
JO - Military Medicine
DO - 10.7205/MILMED.172.8.858
DA - 2007-08-01
UR - https://www.deepdyve.com/lp/oxford-university-press/a-procedure-for-soft-tissue-foreign-body-removal-under-real-time-YoZds1U7cM
SP - 858
EP - 859
VL - 172
IS - 8
DP - DeepDyve
ER -