April 21, 2021

REBEL Core Cast 54.0 Wound Care I – Foreign Bodies

Take Home Points

  • FBs are a very common complication of wounds.
  • X-ray is poor at detecting foreign bodies
  • US is a tremendous tool and be used dynamically at the bedside to assist w FB extraction
  • Prophylactic antibiotics are not routinely recommended

REBEL Core Cast 54.0 – Wound Care I – Foreign Bodies

Click here for Direct Download of Podcast

How common are Foreign Bodies?

  • 11 million patients present to the ED with traumatic wounds every year
  • Approximately one patient every 3 seconds
  • 1 in 7 wounds (7-15%) may contain foreign bodies
  • We miss 1/3rd (38%) foreign bodies on initial evaluation.

What Complications arise from foreign bodies?

Delays in treatment or missed foreign body may lead to:

  • infection
  • delayed wound healing
  • inflammation
  • loss of function

Missed FB is a common reason for malpractice claims secondary to complications in wound care management.

  • The payouts are small
  • But the impact is significant due to large number of patients
  • Claims due to wound care complications netted 3% to 11% of all dollars paid out

How do we evaluate wounds for foreign bodies?

A detailed history and thorough physical exam are vital

  • Typically our patients can reliably tell the mechanism and type of foreign body
  • Altered patients may be unable to provide Information
  • These situations can provide a diagnostic dilemma

HPI: Obtain Information:

  • Type of foreign body
  • Mechanism of injury
  • Tetanus
  • Past medical history: assessment of high-risk individuals requiring antibiotics

Physical exam:

  • Note range of motion, 
  • Tendon function
  • Signs of infection
  • Neurovascular exam: sensation, pulses, cap refill
  • Palpable foreign body
  • Skin discoloration

Considerations for Imaging:

  • Inability to completely visualize the depth of wound
  • Deep wounds caused by glass
  • Patient believes there is a foreign body
  • Small, thin, breakable, or brittle object
  • Object easily be buried beneath the skin
  • Severe wound pain
  • Painful mass
  • Discoloration under the skin
  • Missing portion of the object
  • Penetration through rubber sole

How good are X-rays for assessing foreign bodies?

X-ray: 

  • Poor sensitivity 
  • Inexpensive and low radiation
  • It can also help identify other injuries
  • Cadaver study: 160 foreign bodies (fresh wood, dry wood, glass, porcelain and plastic fragments) implanted in cadaver feet and subsequently imaged with different modalities
  • Overall sensitivity and specificity for foreign body detection was 29% and 100% for radiographs,
  • Glass alone sensitivity was 53%

Is CT better than Xray?

  • Overall sensitivity and specificity foreign body detection is 63% and 98% for CT
  • Glass alone sensitivity was 100%
  • CT is a good choice if you know what the foreign body will show up (glass of metal)

When should you order a CT scan?

  • CT scan should be considered the type of foreign body is known.
  • If the foreign body is compressing a neurovascular structure
  • CT imaging in retained foreign bodies from older injuries may show additional Information like infection and abscess, which can change/guide management

Is there a role for Ultrasound in the detection of foreign bodies?

  • With trained provider, ultrasound sensitivity for the localization of foreign bodies can reach 96.7% – 100%
  • US is that its a dynamic imaging modality
  • Can use it at the bedside to help guide our extraction

Which foreign bodies need specialty consultation?

  • Significantly deep structures
  • Failed retrieval requiring further dissection
  • Neurovascular compromise
  • Objects located near vascular structures
  • Concerns for compartment syndrome

Which patients with FBs need antibiotics?

  • Heavily contaminated puncture wounds 
  • Patients with: Diabetes mellitus, Immunodeficiency, 
  • Retained organic foreign body
  • Injuries through an intact shoe
  • Follow wounds closely for evidence of infection regardless of the decision to treat with antibiotics

Take-Home Points:

  • FBs are a very common complication of wounds.
  • X-ray is poor at detecting foreign bodies
  • US is a tremendous tool and be used dynamically at the bedside to assist w FB extraction
  • Prophylactic antibiotics are not routinely recommended

Read More

REFERENCES:

  1. Rui P, Kang K. National Hospital Ambulatory Medical Care Survey: 2017 emergency department summary tables. National Center for Health Statistics. [Link is HERE]
  2. Davis J et al. Diagnostic Accuracy of Ultrasonography in Retained Soft Tissue Foreign Bodies: A Systematic Review and Meta-analysis. Acad Emerg Med. 2015. PMID: 26111545
  3. Pfaff JA, Moore GP. Reducing risk in emergency department wound management. Emerg Med Clin North Am. 2007. PMID: 17400081
  4. Pattamapaspong N. et al. Accuracy of radiography, computed tomography and magnetic resonance imaging in diagnosing foreign bodies in the foot. Radiol Med. 2013. PMID: 22744349
  5. Cummings P, Del Beccaro MA. Antibiotics to prevent infection of simple wounds: a meta-analysis of randomized studies. Am J Emerg Med. 1995. PMID: 7605521
  6. Moran GJ, Talan DA, Abrahamian FM. Antimicrobial prophylaxis for wounds and procedures in the emergency department. Infect Dis Clin North Am. 2008. PMID: 18295686
  7. Singer AJ, Dagum AB. Current management of acute cutaneous wounds. N Engl J Med. 2008. PMID: 18768947
  8. Rubin Get al. Nail puncture wound through a rubber-soled shoe: a retrospective study of 96 adult patients. J Foot Ankle Surg. 2010. PMID: 20797584
  9. Ellsworth Wright MD & Brandon Somwaru DO, “POCUS and Soft Tissue Foreign Bodies”, REBEL EM blog, January 18, 2021. [Link is HERE]
  10. Lyon M et al.
  11. Detection of soft tissue foreign bodies in the presence of soft tissue gas. J Ultrasound Med. 2004. PMID: 15154535

Post Peer Reviewed By: Salim R. Rezaie, MD (Twitter: @srrezaie)

Cite this article as: Anand Swaminathan, "REBEL Core Cast 54.0 Wound Care I – Foreign Bodies", REBEL EM blog, April 21, 2021. Available at: https://rebelem.com/rebel-core-cast-54-0-wound-care-i-foreign-bodies/.
The following two tabs change content below.

Anand Swaminathan

Clinical Assistant Professor of Emergency Medicine at St. Joe's Regional Medical Center (Paterson, NJ)
REBEL EM Associate Editor and Author
3 Comments
  • Zedu Weekly Wrap - 23 April 2021
    Posted at 19:03h, 22 April Reply

    […] REBEL Core Cast 54.0 Wound Care I – Foreign Bodies […]

  • Sam D.
    Posted at 14:38h, 05 May Reply

    Must every foreign body be removed? What about the small, difficult to visualize and remove foreign bodies such as wood splinter or broken glass? This can be difficult to visualize with XR, CT, or US and can challenging to see with the naked eye, thus making removal nearly impossible. Especially with small children during a busy solo shift.

    • Salim Rezaie
      Posted at 14:43h, 05 May Reply

      Obviously contaminated wounds will be difficult to get everything out. Do everything you can to get the big pieces out and try your best to get the small pieces too, but obviously this is not going to be possible in every situation. If you are unable to get everything out, which happens sometimes, discuss this with the patient and document this discussion. Ensure good follow up as there is high risk for infection.

Post A Comment

Time limit is exhausted. Please reload CAPTCHA.

0