Ultrasound versus radiography in the detection of soft-tissue foreign bodies

Musculoskeletal infections through direct inoculation

Musculoskeletal infections consist of different clinical conditions that are commonly encountered in daily clinical settings. As clinical findings and even laboratory tests cannot always be specific, imaging plays a crucial role in the diagnosis and treatment of these cases. Musculoskeletal infections most commonly occur secondary to direct inoculation into the skin involuntarily affected by trauma, microorganism, foreign bodies, or in diabetic ulcers; direct infections can also occur from voluntary causes due to surgery, vaccinations, or other iatrogenic procedures. Hematogenous spread of infection from a remote focus can also be a cause for musculoskeletal infections. Risk factors for soft tissue and bone infections include immunosuppression, old age, corticosteroid use, systemic illnesses, malnutrition, obesity, and burns. Most literature discusses musculoskeletal infections according to the diagnostic tools or forms of infection seen in different soft tissue anatomical planes or bones. This review article aims to evaluate musculoskeletal infections that occur due to direct inoculation to the musculoskeletal tissues, by focusing on the traumatic mechanism with emphasis on the radiological findings.

Imaging of MSK infections in the ER

Musculoskeletal infections in the ER are not an uncommon presentation. The clinical context is critical in determining the suspicion for infection and degree of tissue involvement which can involve all layers from the skin to bones. The location, extent, and severity of clinically suspected infection directly relate to the type of imaging performed. Uncomplicated cellulitis typically does not require any imaging. Localized and superficial infections can mostly be evaluated with ultrasound. If there is a diffuse site (an entire extremity) or suspected deeper involvement (muscle/deep fascia), then CT is accurate in diagnosing, widely available, and performed quickly. With potential osseous involvement, MRI is the gold standard for diagnosing acute osteomyelitis; however, it has the drawbacks of longer scan times, artifacts including patient motion, and limited availability.

Ultrasound compared with projection radiography for the detection of soft tissue foreign bodies - A technical note

INTRODUCTION

Soft tissue foreign bodies (STFBs) present a diagnostic challenge depending on their composition. Untreated complications can arise, namely infection through to loss of function. General (projection) radiography is recommended as the first line imaging examination. However, some STFBs are radiolucent, leading to false negative radiographs. The aim of this in vitro study was to compare ultrasound with projection radiographs for the detection of a range of different types of STFB.

METHOD

Ethical approval (for use of participants to evaluate images) was granted by the Higher Education Institute's departmental Ethics Committee. Seven hand phantoms were created from a water, gelatine and psyllium mix. A different STFB (radiolucent and radiopaque) was inserted into six phantoms, with the seventh being a control. Ultrasound and projection radiograph images were generated of each phantom. Participants (academics and radiography students) reviewed all images.

RESULTS

50 responses were received from a study population of approximately 400, (10 academics, 40 students). The ability of ultrasound to detect radiolucent foreign bodies performs well compared with projection radiography: sensitivity 94% versus 9%, specificity 90% versus 88%. For radiopaque foreign bodies the data was more mixed: sensitivity 96% versus 99%, specificity 90% versus 88%.

DISCUSSION

These data suggest that ultrasound is superior to projection radiography for the detection of radiolucent STFBs. Limitations include the lack of formal postgraduate ultrasound training within the study population and a lack of simulated bony structure within the hand phantoms.

IMPLICATIONS FOR PRACTICE

Ultrasound has the potential to be a useful modality in the detection of STFBs, particularly radiolucent objects. There are associated challenges such as conducting ultrasound in the vicinity of a wound, but further exploration of this application of ultrasound is warranted.

Dermatoscopic and Dermatopathologic Features of a 3-Year-Old Buried Polypropylene Suture

ABSTRACT

Cutaneous foreign bodies are a well-known cause of delayed wound healing and complications such as abscesses, fistula formation, and secondary infections. Polypropylene sutures are widely utilized in cutaneous surgery because they easily travel through tissues while eliciting minimal tissue reactions. Despite these advantages, retained polypropylene sutures can cause complications. The authors report a case of a retained polypropylene suture that remained buried after a total excision 3 years prior. It started to cause cutaneous symptoms when the patient began exercising 1 week prior to presentation. The authors also examine the dermatoscopic and dermatopathologic features and other complications related to retained polypropylene sutures that have been reported in the literature.

Comparison of ultrasonography and conventional radiography in the diagnosis of extremity fractures in the emergency department

Objective: The purpose of the study is to compare the diagnostic accuracy (sensitivity and specificity) of ultrasonography (USG) with that of conventional radiography (CR), the standard imaging modality used to diagnose acute extremities fractures. Materials and Methods: The prospective investigation examined 245 patients with clinical symptoms of an extremity fracture. Radiography (anteroposterior and lateral radiographs for each patient, oblique if necessary) and USG were performed on all participants and compared with all the results. Results: CR verified 98.5% of 132 patients who were determined to have extremities fractures with USG. CR, on the other hand, confirmed 99.1% of 112 patients who were reported to have no extremities fractures by USG. The sensitivity (detection of fractures based on USG of patients with fractures detected based on the CR imaging) was 99.2% (95%CI=95.8-99.9); selectivity (no fracture was detected based on USG of patients with no fracture detected based on the CR imaging) was 98.2% (95%CI=93.8-99.7); the positive predictability was 98.48% (95%CI=94.2-99.6), whereas the negative predictability value was 99.1%(95%CI=94-99.8). Conclusion: USG and CR showed similar diagnostic performances in the diagnosis of extremity fractures. USG can be considered an alternative to CR in the examination of extremity fractures with comparable diagnostic performance.

Imaging of Musculoskeletal Soft-Tissue Infections in Clinical Practice: A Comprehensive Updated Review

Musculoskeletal soft-tissue infections include a wide range of clinical conditions that are commonly encountered in both emergency departments and non-emergency clinical settings. Since clinical signs, symptoms, and even laboratory tests can be unremarkable or non-specific, imaging plays a key role in many cases. MRI is considered the most comprehensive and sensitive imaging tool available for the assessment of musculoskeletal infections. Ultrasound is a fundamental tool, especially for the evaluation of superficially located diseases and for US-guided interventional procedures, such as biopsy, needle-aspiration, and drainage. Conventional radiographs can be very helpful, especially for the detection of foreign bodies and in cases of infections with delayed diagnosis displaying bone involvement. This review article aims to provide a comprehensive overview of the radiological tools available and the imaging features of the most common musculoskeletal soft-tissue infections, including cellulitis, necrotizing and non-necrotizing fasciitis, foreign bodies, abscess, pyomyositis, infectious tenosynovitis, and bursitis.

Nail Puncture Wound Through a Rubber-Soled Shoe: Should We Take Every Patient to the Operating Room?

Nail puncture wounds through rubber-soled shoes, when presenting acutely, have a deceivingly benign appearance. High index of suspicion for a retained rubber piece should be maintained by the physician. This study investigates whether preoperative ultrasound examination can rule out a foreign body and reduce the need for surgery. It is a retrospective cohort of 125 patients with deep nail puncture wounds through a rubber-soled shoe, who underwent surgical exploration between 2008 and 2018. All patients had a preoperative ultrasound examination for detection of a rubber foreign body. The patients' median age was 29, and 112 (89.6%) were males. Median time of presentation was 1 day, but there were patients who presented up to 90 days after injury (mean 5.1 ± 15.6 days). Foreign bodies, ranging 1 to 4 mm in diameter, were surgically removed in 37 (29.6%) patients. Only 16 of these patients had a positive preoperative ultrasound examination, corresponding to sensitivity of 43.2%. Specificity of the ultrasound examination was 95%. Ultrasound examination has low sensitivity for detection of foreign bodies following a puncture wound of the foot. This is attributable to the small size of the foreign bodies in this scenario and to the complexity of sonography in this location. We conclude that ultrasound cannot be used to rule out foreign body in the foot, and should not be relied on when deciding to avoid surgery. Nevertheless, it can be a helpful adjunct preoperatively, as an assessment of the foreign body size and location.

Ultrasonography in soft-tissue foreign-body detection: a phantom study

Purpose

Foreign body implantation into the soft tissues, either in the early period or late period, is a common cause of emergency department admissions. Direct X-rays are preferred in the diagnosis of soft-tissue foreign-bodies. Herein, we aimed to analyse the detection rates of foreign bodies of various sizes placed in phantoms implanted into soft tissue by ultrasonography.

Material and methods

A total of 740 pieces of chicken fillet were prepared as phantoms. No objects were implanted into 100 phantoms. We inserted glass, porcelain, plastic, wood, pencil tip, chicken bone, iron, walnut shell, and fishbone with a length of < 1 cm, 1-3 cm, and 3-5 cm into 20 pieces of chicken phantom in each size of foreign body (FB). In addition, 1-3 cm long peanut shell, < 1 cm rose spikes, < 1 cm cactus thorns, < 1 cm pellets, and < 1 cm staples were inserted into 20 pieces of chicken for each object. Each of the chicken pieces was placed inside a latex glove and examined by ultrasonography.

Results

The sensitivity of ultrasonography in the detection of the cactus thorn was 5%, whereas it ranged between 82.5 and 100% for other objects. For glass, plastic, wood, iron, and fishbone, we found that when the size exceeded 1 cm, the sensitivity increased.

Conclusions

In the evaluation of soft tissue FBs, as the size of the FBs increases, the diagnostic value of ultrasonography increases.

Occult traumatic impaled foreign body, a challenging diagnosis of severe chronic lower extremity radicular pain

The investigation of embedded soft tissue foreign bodies relies heavily on radiological imaging. The prompt identification of these objects is critical as retained foreign bodies may lead to serious infection or chronic debilitating pain depending on anatomical location. In this report, we present a case of a radiographically occult traumatically implanted foreign body in a 15-year-old female after a high-speed motor vehicle accident. Initial computed tomography (CT) scan was unremarkable and exploration under anesthesia demonstrated no other significant findings, yet the patient continued to suffer severe refractory radicular pain with marked limitation of daily function. It was not until 12 weeks after the accident that a magnetic resonance image (MRI) of the pelvis revealed a deep sinus tract with central low magnetic resonance (MR) signal, raising suspicion for a retained foreign body. A 10-centimeter plastic foreign body extending from the patient's coccyx to the sciatic foramen was identified and surgically removed resulting in immediate symptom relief. This case illustrates that the detection of a retained foreign body is not always straightforward and multiple imaging modalities may be necessary for accurate diagnosis. We also discuss the most appropriate diagnostic imaging algorithm when a foreign body of the musculoskeletal system is suspected.

Multimodality Imaging of Foreign Bodies: New Insights into Old Challenges

Traumatic wounds and lacerations are a common reason for patients to present to emergency departments, with retained foreign bodies (FBs) accounting for 7%-15% of cases, particularly those involving the extremities. These retained materials result in a granulomatous tissue response known as an FB reaction, a pathologic attempt to isolate the FB from the host. The most common FB materials are glass, metal, and wood, but other compositions can also be found, such as plastic and animal-derived materials. Clinical history, physical examination, and wound exploration are essential in investigation of retained material but are not sufficient to exclude an FB, and additional investigation is required. Imaging evaluation is a useful tool to help depict and locate an FB, assess possible complications, and guide removal. Conventional radiography, the first-line method in this scenario, is a widely available low-cost depiction method that has good sensitivity for depicting FBs. If the retained material is not depicted at conventional radiography, US can be performed. US is highly sensitive in depicting both radiolucent and radiopaque FBs in superficial locations. For deeper objects, CT may be necessary. MRI is the best imaging modality to delineate local soft-tissue and osseous complications. Retained FBs can result in early and delayed complications, with infection being the most frequent complication. To avoid preventable morbidities related to FBs, radiologists should be familiar with imaging findings and provide essential information to help the attending physician treat each patient. Online supplemental material is available for this article. ^©RSNA, 2020.

Identification of various orthodontic materials as foreign bodies via panoramic radiography, cone beam computed tomography, magnetic resonance imaging, and ultrasonography: an in vitro study

OBJECTIVES

We evaluated the in vitro detection sensitivity of orthodontic materials (serving as foreign bodies) using panoramic radiography, cone beam computed tomography (CBCT), magnetic resonance imaging (MRI), and ultrasonography.

METHODS

Five different orthodontic materials served as foreign bodies: titanium-molybdenum alloy wire (TMA; ORMCO, Orange, CA, USA; 0.017 × 0.025 in in cross-sectional dimensions and 1 cm long); stainless steel bracket tooth #34 (American Orthodontics, Sheboygan, WI, USA); a monocrystalline, sapphire ceramic bracket tooth #34 (Skyortho Dental Supplies Medical, China); a polycrystalline alumina clear bracket, Damon clear bracket tooth #34 (ORMCO); and a 1 × 1 × 0.1 cm polyurethane-based thermoplastic material, Invisalign clear aligner (Align Technology, San Jose, CA, USA). Panoramic radiography, CBCT, MRI, and ultrasonography were used, and four observers scored all findings independently.

RESULTS

The TMA and stainless steel bracket were visualised in all fields by panoramic radiography and CBCT. The sapphire and Damon brackets were very clear on CBCT. The Invisalign in air was evident only on CBCT. MRI was unable to identify any material in muscle. Ultrasonography detected the TMA, sapphire bracket, and the Invisalign in muscle but only the TMA on bone.

CONCLUSIONS

Panoramic radiography does not reveal nonmetallic orthodontic equipment in air and reveals them only poorly in muscle. CBCT was the optimal imaging modality for all materials in all fields except for the Invisalign in muscle and bone. CBCT was the only method that revealed the Invisalign in air. MRI and ultrasonography should be used to detect orthodontic materials in muscle.

Clinical Considerations in Initial Evaluation and Treatment of Hardhead Catfish Spine Puncture Wounds

A 17-year-old male presented to our ED complaining of pain and swelling at the base of the first metacarpal after attempting to remove a catfish from his fishing line 12 hours prior to arrival. Radiographic images demonstrated a foreign body (FB), which was detectable by ultrasound. Hand surgery was consulted and took the patient to the operating room for exploration and removal of two serrated radiopaque catfish spines that were deeply embedded in the left thumb. Conclusion. Penetrating injury from hardhead catfish (Ariopsis felis) spines can cause hidden FB, envenomation, infection, and secondary damage to nearby structures. Imaging should be done for these patients to ensure they obtain timely and complete extraction of the venomous structures. Surgery should be consulted for operative management to avoid damage on removal of the catfish spine remnants.

Photoacoustic Imaging and Sensing: A New Way to See the Eye

Purpose: Photoacoustics (optoacoustics) is a hybrid technology utilizing light excitation of acoustic responses in targets of interest. It has found numerous applications in biomedicine, including eye research, because of its ability to report both morphological and functional data about the interrogated tissue. This presentation will give an overview of current applications. Methods: Wavelength-dependent absorption of light in a tissue chromophore causes local heating, leading to a thermoelastic expansion-contraction cycle. If nanosecond pulses of light are used to excite this process, the resulting pressure wave is an ultrasound signal propagating through the tissue and detectable at the tissue surface. This is highly advantageous because of the known properties of ultrasound propagation in tissue and the ability to use standard, medical ultrasound equipment for detection. The time of arrival and amplitude of ultrasound signals provide information about the location and nature of the absorber. Results: Due to the wavelength dependence of the photoacoustic response, functional and physiological applications are possible. For example, retinal oximetry can be determined from the different optical absorption properties of oxy- and deoxyhemoglobin. Multispectral imaging of the posterior segment can identify pigments such as melanin or lipofuscin or the nature of foreign bodies. The technique can be combined with other imaging modalities such as ultrasound and optical coherence tomography to produce high-resolution images of retinal structures along with functional information. Conclusion: Photoacoustic technology is a powerful noninvasive tool for ocular research and to study ocular morphology, fundamental physiological parameters, cellular responses, and molecular expression.

ACR Appropriateness Criteria® Acute Trauma to the Foot

Acute injuries to the foot are frequently encountered in the emergency room and in general practice settings. This publication defines best practices for imaging evaluations for several variants of patients presenting with acute foot trauma. The variants include scenarios when the Ottawa rules can be evaluated, when there are exclusionary criteria, and when suspected pathology is in anatomic areas not addressed by the Ottawa rules. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.

Ultrasound Evaluation of Soft-Tissue Foreign Bodies by US Army Medics

Objective:

The study's primary objective was to determine army medics' accuracy performing bedside ultrasound (US) to detect radiolucent foreign bodies (FBs) in a soft-tissue hand model. Secondary objectives included the assessment of US stand-off pad effects on soft-tissue FB detection rates and assess established FB detectable lower limit size of 2 mm.

Methods:

Prospective, single blinded, observational study of US-naïve Army medics' abilities utilizing bedside US to detect wooden FBs in a chicken thigh model with or without an US stand-off pad. After a 2 h training period, medics' abilities to detect 1–3 mm FB utilizing a SonoSite^® M-Turbo US and 13–6 MHz linear probe were assessed.

Results:

After a 2 h training period, 28 medics had a sensitivity and specificity of 73% and 78% detecting 1–3 mm FBs utilizing standard US equipment. The medics' sensitivity and specificity were both 78% in detecting radiolucent FBs 2 mm and larger without a stand-off pad. The sensitivity and specificity decreased to 48%, 62%, and 67% when utilizing a stand-off pad to detect 1, 2, and 3 mm soft-tissue FBs. Sub 2 mm detection rates decreased from 82% for 2 mm FB to 64% for 1 mm FBs without utilizing a stand-off pad.

Conclusion:

Army medics with minimal US experience successfully identified FBs embedded in hand models with accuracies similar to radiologists and emergency medicine physicians. However, radiolucent FB detection sensitivity and specificity decreased in US-naïve Army medics utilizing stand-off pads. In addition, this study reconfirmed the lower limit of FB detection rates at 2 mm. These results support Army medics' utilization of US to evaluate for superficial radiolucent FBs of the hand.

Ultrasound Assisted Detection and Removal of Wooden Foreign Bodies in Soft Tissue

Soft tissue foreign bodies represent a common cause for emergency department visits. Diagnosis may be difficult especially with non-radiopaque foreign bodies. Undetected wooden foreign bodies can cause significant morbidity, repeat visits, high cost, and extensive surgery. We report a case in which ultrasound was used in the Emergency Department to detect and remove wooden foreign bodies from the soft tissue. Ultrasound and other imaging modalities that may aid in the early diagnosis are discussed.

Ultrasound-Guided Foreign Body Removal

A gentleman suffering from right leg penetrating injury presented to a local accident and emergency department. The physical examination did not suggest an embedded foreign body, and he was discharged after local wound dressing. Because of persisting symptoms, he attended another hospital later where an unguided surgical exploration was performed but no foreign body was identified. He was then referred to another hospital, his third one, for further management. The X-ray finding was unremarkable but ultrasound showed a hyperechoic foreign body. Subsequently, ultrasound-guided foreign body removal was performed and a wooden splinter was successfully removed.

Multimodality Imaging Approaches for Evaluating Traumatic Extremity Injuries: Implications for Military Medicine

Significance: Military service members are susceptible to traumatic extremity injuries that often result in limb loss. Tremendous efforts have been made to improve medical treatment that supports residual limb function and health. Despite recent improvements in treatment and novel prosthetic devices, many patients experience a wide range of clinical problems within residual limbs that can negatively impact the progress of rehabilitation programs while also impairing functional capacity and overall quality of life. Recent Advances: In addition to existing standard imaging modalities that are used for clinical evaluation of patients suffering from traumatic extremity injury, novel noninvasive imaging techniques are in development that may facilitate rapid and sensitive assessment of various aspects of traumatic extremity injuries and residual limb health. Critical Issues: Despite recent advances, there remains a clinical need for noninvasive quantitative imaging techniques that are capable of providing rapid objective assessments of residual limb health at the time of initial presentation as well as after various forms of medical treatment. Future Directions: Ongoing development of imaging techniques that allow for assessment of anatomical and physiological characteristics of extremities exposed to traumatic injury should greatly enhance the quality of patient care and assist in optimizing clinical outcomes.

Comparison of Ultrasonography, Magnetic Resonance Imaging and Cone Beam Computed Tomography for Detection of Foreign Bodies in Maxillofacial Region

INTRODUCTION

Foreign Bodies (FBs) entrapped in the maxillofacial region have a high prevalence due to trauma and accidents. Accurate localization of FBs and verifying their type and size are critical to assist the surgeon in their fast retrieval with minimal tissue damage.

AIM

To assess and compare the imaging modalities including MRI, ultrasonography and Cone Beam Computed Tomography (CBCT) for detection of different types of FBs.

MATERIALS AND METHODS

In this study, four types of FBs including pieces of normal glass, barium glass, wood and pebbles with equal sizes were placed randomly in two sheep heads in different locations such as upper lip, maxillary sinus and body of mandible as FBs and subjected to MRI, ultrasound and CBCT. The images were interpreted by expert observers and the data was analysed using the stata 11 software, kappa test and chi-square test.

RESULTS

Sensitivity of CBCT, MRI and ultrasound for detecting foreign bodies was 79.19%, 20.83% and 33.33%, respectively. None of the imaging modalities could clearly visualize wooden FBs. Among different FBs, pebbles and barium glass were detected more accurately by radiographic imaging technique. The sensitivity of CBCT, ultrasound and MRI for pebbles was 100%, 33.33% and 16.67%, respectively. The sensitivity of CBCT, ultrasound and MRI for barium glass was 100%, 33.33% and 41.69%, respectively. The sensitivity of CBCT, ultrasound and MRI for wood was 33.33%, 33.33% and 16.67%, respectively. Specificity of all three imaging modalities was 100%. Diagnostic accuracy of all three imaging modalities was higher for detection of FBs in the upper lip than those in the body of mandible, and FBs in the latter location had higher detection accuracy than those in the maxillary sinus.

CONCLUSION

Among the three imaging modalities, CBCT had the highest diagnostic sensitivity for the examined FBs. The highest diagnostic sensitivity was noted for pebbles and barium glass.

Ultrasound-Assisted Removal of A Fishbone Stuck in A Tongue in the Emergency Department

BACKGROUND

Foreign body (FB) impaction in the oropharyngeal region-and specifically the tongue-is a common problem in the emergency department that often requires specialty consultation and admission for operative intervention. Over the years, the use of point of care ultrasound (POCUS) has increased ease and success of FB removal in other anatomic regions, but is only rarely reported for extraction of FB from the tongue outside of the operating room.

CASE REPORT

This case demonstrates a unique case of ultrasound-guided removal of a fishbone from the tongue in the emergency department after blind attempts failed. Operative intervention and admission were initially avoided; however, because of initial failed attempts and blind dissection before the use of POCUS, the patient presented a day later requiring admission for postprocedural tongue swelling and edema. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Emergency physicians should be aware that POCUS may assist in FB localization in the tongue.

Culture-Proven Thorn-Associated Infections in Arizona: 10-Year Experience at Mayo Clinic

Background

Thorn injuries are common in the desert Southwest; however, the frequency and microbiology of thorn-associated infections have not been systematically described. Most information comes from case reports describing infections from atypical or environmental microorganisms. Our aim was to summarize the spectrum of thorn-associated infections.

Methods

We conducted a retrospective review of electronic health records for patients presenting to our institution from January 1, 2005 to December 31, 2014 for treatment of thorn-associated injuries and then focused on the patients with cultures.

Results

Of 2758 records reviewed, 1327 patients had thorn-associated injuries; however, only 58 (4.4%) had cultures. Of these patients, 37 (64%) had positive findings; 5 had polymicrobial infection. The most commonly identified organisms were Staphylococcus aureus (n = 22, 59.0%) and coagulase-negative Staphylococcus species (n = 8, 21.6%). Other pathogens included Nocardia species (n = 3, 8.1%), Streptococcus species (n = 2, 5.4%), Gram-negative bacteria (n = 2, 5.4%), Aspergillus species (n = 2, 5.4%), Paecilomyces lilacinus (n = 1, 2.7%), and Candida species (n = 1, 2.7%). There were no infections caused by Pantoea agglomerans, Sporothrix schenckii, or Coccidioides spp.

Conclusions

In contrast to most published case reports, we found that typical cutaneous microorganisms, such as Staphylococcus species, caused the majority of culture-positive, thorn-related infections.

Foot Infections

Infections of the foot are very variable, some being complex in nature, causing pain, morbidity, and even mortality. In patients with diabetes mellitus, foot infections are common, ranging from chronic bacterial or fungal infections to serious limb-threatening ones. To manage infections, a sound knowledge of anatomy is essential. This article reviews the problems with respect to recent evidence and provides pathways to management and suggestions of changes with potential to wound healing.

Blade of Grass as an Unusual Cause of Recurrent Facial Cutaneous Sinus Tract: A Clinical Case

The presence of an embedded foreign body in the oral and maxillofacial region is not unusual, but the impaction of a foreign body with vegetative nature is rare. Prompt diagnosis and surgical removal of these foreign bodies will minimize their associated complications. This case report presents a patient with recurrent submandibular abscess and persistent facial cutaneous sinus tract caused by a retained blade of grass inside the facial soft tissue. The fact that the plain radiograph misdiagnosed the presence of a foreign body meant that the pathology persisted for about three months, and the patient underwent hospitalization, surgical procedures, and antibiotic regimens; however all of these failed until the foreign body was detected and removed. Conclusion. To avoid misdiagnosis of foreign body presence in the orofacial region, notably suspected foreign bodies with low radiopacity, the clinician must perform careful clinical examination and use the ultrasonography. Also, in the uncertain cases where the pathology persists, despite having undertaken surgical procedures and antibiotic regimens, the clinician should pay more attention to the patient's history which may suggest the presence of the foreign body.

Not as Straight(forward) as an Arrow: Ultrasound Use to Detect a Carbon-Fiber Foreign Body: A Case Report

CASE

A fifteen-year-old boy sustained an archery injury when a carbon-fiber arrow shaft embedded in the volar aspect of his left forearm. The shaft was removed, but at a follow-up visit he still felt the sensation of a retained foreign body in the tissue. Although radiographs were negative, ultrasound examination found three foreign bodies of various lengths still located in the soft tissue. Further surgery removed the objects without difficulty.

CONCLUSION

Ultrasound examination can be a valuable diagnostic tool when radiographs yield inconclusive results after penetrating wounds due to radiolucent foreign bodies.

Foreign Body in Jugal Mucosa

Introduction Foreign body in the oral cavity may be asymptomatic for long time and only sometimes it can lead to a typical granulomatous foreign body reaction. Some patients may complain of oral pain and present signs of inflammation with purulent discharge. A granuloma is a distinct, compact microscopic structure composed of epithelioid-shaped macrophages typically surrounded by a rim of lymphocytes and filled with fibroblasts and collagen. Nowadays, the increase of cosmetic invasive procedures such as injection of prosthetic materials in lips and cheeks may lead to unusual forms of inflammatory granulomas. Objectives Describe an unusual presentation of a foreign body reaction in the buccal mucosa due to previous injection of cosmetic agent. Resumed Report A 74-year-old woman was referred to the Department of Otorhinolaryngology, Head and Neck Surgery to investigate the presence of multiple painless, bilateral nodules in the buccal mucosa, with progressive growth observed during the previous 2 months. The histologic results showed a foreign body inflammatory reaction. Conclusion Oral granulomatosis lesions represent a challenging diagnosis for clinicians and a biopsy may be necessary. Patients may feel ashamed to report previous aesthetic procedures, and the clinicians must have a proactive approach.

Use of a slit-lamp microscope for treating impacted facial foreign bodies in the emergency department

Identifying, locating, diagnosing, and treating small foreign bodies (FBs) in soft tissues is a challenge for emergency physicians in the emergency department. Additionally, potential complications owing to the remnant FBs are medico-legally significant. The efficacy of conventional imaging methods such as radiography, computed tomography, and ultrasonography are largely limited in visualizing FBs<2-mm. The slit-lamp microscope, still unfamiliar to some emergency physicians, could be used to facilitate the treatment of FBs impacted in soft tissues. In this paper, we present a case that would have been difficult to treat without the help of the slit-lamp microscope; the patient presented with numerous particulate facially impacted FBs that were too small to be observed under plain sight or with radiography. Based on our experience, the slit-lamp microscope could be a useful tool for treating patients with miniscule and stubborn impacted FBs in the emergency department.

Point-of-care Ultrasound: A New Tool for the Identification of Gastric Foreign Bodies in Children?

BACKGROUND

Point-of-care ultrasound (POCUS) has been used to identify ingested gastric foreign bodies. Our aim was to describe the sonographic findings of radiopaque and radiolucent gastric foreign bodies (FBs) in children.

CASE REPORT

Three children ingested different FBs. Two were confirmed with standard radiographs, one was not identified radiographically but was passed in the stool. All three objects were initially found in the stomach using POCUS. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: With increased training and comfort, emergency physicians may begin to use POCUS for identification and monitoring of ingested FBs in the pediatric population.

Diagnostic Accuracy of Ultrasonography in Retained Soft Tissue Foreign Bodies: A Systematic Review and Meta-analysis

OBJECTIVES

Open wounds with the potential for retained foreign bodies are frequently seen in the emergency department (ED). Common foreign bodies, such as wood or glass, are often missed on physical examination and conventional radiography. The increased use of ultrasonography (US) in the ED presents an opportunity to better identify retained soft tissue foreign bodies, and understanding of its test characteristics is desirable. The authors set out to determine the test characteristics of US for detection of soft tissue foreign bodies by performing a systematic review and meta-analysis of the existing literature.

METHODS

This was a thorough, systematic review of OVID Medline, SCOPUS, and Cochrane databases and a limited review of Directory of Open Access Journals, Google Scholar, and ClinicalTrials.gov to identify clinical studies examining the diagnostic accuracy of US in the identification of retained soft tissue foreign bodies. Studies were selected for full-text review by two independent reviewers to determine if they met inclusion criteria. Results were pooled for test characteristics using STATA and assessed for risk of bias and applicability using the QUADAS-2 tool.

RESULTS

This systematic search strategy identified 5,059 unique articles, and 17 articles met inclusion criteria. Pooled sensitivity and specificity were, respectively, 72% (95% confidence interval [CI] = 57% to 83%) and 92% (95% CI = 88% to 95%). Overall quality of the studies was low and interstudy heterogeneity was high (I(2)  = 90%, 95% CI = 80% to 100%).

CONCLUSIONS

Ultrasonography is highly specific and moderately sensitive in the identification of retained soft tissue foreign bodies; however, studies to date have a high degree of heterogeneity and a high risk of bias.

Detecting foreign bodies in a head laceration

Open wounds represent a potential area of medicolegal risk if foreign bodies are not identified prior to wound closure. The importance of imaging of lacerations was underscored by a recent case where a 20-year-old male collided with a friend's mouth on a trampoline sustaining a simple, superficial scalp laceration. The wound was evaluated in typical fashion including irrigation and local exploration and was prepared for closure. The friend was then evaluated and noted to have multiple extensive dental fractures. An increased index of suspicion generated further evaluation of the first patient's wound. Plain radiography obtained of the first patient's skull was noted to have bony foreign bodies consistent with teeth, which were then removed after further exploration. Superficial wounds are common and complications arising from retained foreign bodies are a potential source of substantial morbidity and consequently medical litigation. This case serves as a reminder to be vigilant and maintain a high index of suspicion regarding the potential for foreign body.

Visibility of different foreign bodies in the maxillofacial region using plain radiography, CT, MRI and ultrasonography: an in vitro study

OBJECTIVES

To compare the usefulness of four imaging modalities in visualizing various foreign bodies of different sizes.

METHODS

Foreign bodies of four sizes (0.5, 1, 2 and 3 mm) including metal, tooth, wood, plastic, stone, glass and graphite were embedded in six fresh sheep heads on bone surface between the corpus mandible and muscle, and inside the tongue muscle. A human dry skull served as an air-filled space. Plain radiography, CT, MRI and ultrasonography were used, and four skilled radiologists rated the findings individually.

RESULTS

All embedded foreign bodies except wood were best visualized using CT. Wood could only be detected using ultrasonography, and then only when fragments were >0.5 mm in size. Plain radiography and CT were almost equally accurate in visualizing metal and graphite. MRI was the least useful imaging technique.

CONCLUSIONS

In cases with suspected foreign bodies in the maxillofacial region, CT seems to be the optimal initial imaging study. Wood, however, could only be detected using ultrasonography.

Toothpick perforation of the intestines presenting as recurrent abdominal pain: possible roles of abdominal ultrasound and MRI

We report the case of a middle-aged man admitted for five months of unexplained left lower quadrant pain. He had been hospitalized on two prior occasions and treated with broad spectrum antibiotics. His clinical presentation was suggestive peritoneal irritation with severe, focal pain on abdominal palpation. Computed tomography scans showed non-specific inflammation in the left lower abdomen with adjacent small bowel wall thickening. Upper endoscopy and colonoscopy were unremarkable on prior admission. Given the severity and focality of the patient’s recurrent abdominal pain he underwent laparoscopy and was found to have a wooden toothpick perforation of the small bowel thirty centimeters from the ileocecal valve requiring partial small bowel resection. The patient did well post-operatively. On retrospective questioning he may have eaten a cabbage roll or bacon wrapped shrimp pierced with a toothpick weeks before the onset of symptoms. Toothpick perforation should be a consideration in edentulous persons with focal, severe abdominal pain and trans-abdominal ultrasound or MRI may be a better choice for detecting wooden foreign objects.

An incidental finding of an intraosseous metallic object within the os calcis

The authors present a case of an incidental finding of a metallic foreign body located within the calcaneus of a 17-year-old girl. Although the presence of foreign material is a common occurrence in the foot, intraosseous metallic bodies are rare, especially so when they present as an incidental finding. A literature review of PubMed using keywords metallic, foreign body, and calcaneus revealed only a single case report, which did not present as an incidental finding. The presentation described here is rare and provides a platform for discussion about possible management options.

Subungual wooden splinter visualized with bedside sonography

Bedside ultrasound has become increasingly important as an adjunct to clinical diagnosis and procedures in the emergency department. It is only recently that this modality, which involves no ionizing radiation, has become incorporated into the pediatric emergency department. We report a case of a 10-year-old boy with a suspected subungual wooden foreign body. Bedside ultrasound was used to identify and characterize the foreign body before removal and then to evaluate for any residual foreign body after removal. A brief review of the technique is presented, including the use of a water bath to enhance visualization of the object and decrease the patient's discomfort. This case highlights the utility of ultrasound in detecting radiolucent soft tissue foreign bodies.

Small metal soft tissue foreign body extraction by using 3D CT guidance: a reliable method

OBJECTIVE

To introduce a useful and accurate technique for the locating and removal of small metal foreign bodies in the soft tissues.

METHODS

Eight patients presented with suspected small metal foreign bodies retained in the soft tissues of various body districts. Under local anesthesia, 3-6 pieces of 5 ml syringe needles or 1 ml syringe needles were induced through three different planes around the entry point of the foreign bodies. Using these finders, the small metal FBs were confirmed under 3D CT guidance. Based on the CT findings, the soft tissues were dissected along the path of the closest needle and the FBs were easily found and removed according to the relation with the closest needle finder.

RESULTS

Eight metal foreign bodies (3 slices, 3 nails, 1 fish hook, 1 needlepoint) were successfully removed under 3D CT guidance in all patients. The procedures took between 35 min and 50 min and the operation times took between 15 min and 25 min. No complications arose after the treatment.

CONCLUSION

3D CT-guided technique is a good alternative for the removal of small metal foreign body retained in the soft tissues as it is relatively accurate, reliable, quick, carries a low risk of complications and can be a first-choice procedure for the extraction of small metal foreign body.

Puncture wounds of the foot

Puncture wounds are common injuries of the foot. Although most puncture wounds are benign, devastating complications are possible without adequate treatment. These injuries can occur in all age groups and in various circumstances. Early diagnosis and appropriate medical and surgical management is paramount in achieving successful outcomes.

Nail puncture wound through a rubber-soled shoe: a retrospective study of 96 adult patients

Nail punctures through rubber-soled shoes expose the foot to the possibility of deep infection and foreign body retention. In this article, we describe characteristics of adult patients who sustained nail puncture wounds through a rubber-soled shoe and were treated at our institution from January 1, 2000, to January 8, 2008. Of the 96 patients, 36 (37.5%) were treated conservatively and 60 (62.5%) were treated surgically in the operating room. Of those treated surgically, 15 (25%) had a foreign body extracted during the operation. The operated group had a longer duration of time from injury to hospital admission than did the nonoperated group (5.0 +/- 6.8 days versus 2.7 +/- 3.8 days, P < .05). Treatment success was observed in 91 (94.8%) of the patients, and the median lag time before admission for the less successfully treated group was longer than that for the successfully treated group (10 days versus 2 days, P < .002); and, the less successfully treated group was more likely to receive antibiotics in the community before hospitalization (100.0% versus 47.2%, P < .06), and was more likely to be diabetic (40.0% versus 9.9%, P < .10). Fever, white blood cell count, and erythrocyte sedimentation rate were not significantly associated with treatment outcome. Success of the treatment did not depend on white blood cell count, erythrocyte sedimentation rate, or fever. Ultrasonography was useful in detecting the presence of a foreign body.

Comparison of the sensitivity for detecting foreign bodies among conventional plain radiography, computed tomography and ultrasonography

OBJECTIVE

The purpose of this study was to compare the sensitivity for detecting foreign bodies among conventional plain radiography, CT and ultrasonography in in vitro models.

METHODS

Seven different materials were selected as foreign bodies with dimensions of approximately 1 x 1 x 0.1 cm. These materials were metal, glass, wood, stone, acrylic, graphite and Bakelite. These foreign bodies were placed into a sheep's head between the corpus mandible and muscle, in the tongue and in the maxillary sinus. Conventional plain radiography, CT and ultrasonography imaging methods were compared to investigate their sensitivity for detecting these foreign bodies.

RESULTS

Metal, glass and stone can be detected with all the visualization techniques used in the study in all of the zones. In contrast to this, foreign bodies with low radiopacity, which could be detected in air with CT, became less visible or almost invisible in muscle tissue and between bone and muscle tissue. The performance of ultrasonography for visualizing foreign bodies with low radiopacity is relatively better than CT.

CONCLUSIONS

Ultrasonography detects and localizes superficial foreign bodies with low radiopacity in the tissues of the body more effectively than CT and conventional plain radiography. However, CT is a more effective technique for visualization of foreign bodies in air than ultrasound and conventional plain radiography.