1
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Druel T, Jalaguier T, Gaillard C, Gazarian A. Recommendations for radiographic assessment of hand wounds. J Hand Surg Eur Vol 2024; 49:499-500. [PMID: 37974361 DOI: 10.1177/17531934231211566] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2023]
Abstract
A retrospective study of 945 hand patients was conducted to determine the relevance of systematic radiographic assessment. An osteoarticular lesion or a radiopaque foreign body was found in 34% of cases. The indications for radiographic assessment should be related to the mechanism of injury.
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Affiliation(s)
- Thibault Druel
- SOS Main, Department of Hand Surgery, Hôpital Edouard Herriot, Lyon, France
| | - Thomas Jalaguier
- SOS Main, Department of Hand Surgery, Hôpital Edouard Herriot, Lyon, France
| | - Christophe Gaillard
- SOS Main, Department of Hand Surgery, Hôpital Edouard Herriot, Lyon, France
- Department of Orthopaedic and Traumatology, Hôpital militaire Desgenettes, Lyon, France
| | - Aram Gazarian
- SOS Main, Department of Hand Surgery, Hôpital Edouard Herriot, Lyon, France
- Department of Hand Surgery, Clinique du Parc, Lyon, France
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2
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Richardson SR, Pope J, Dickson L, Hart LB, Wilson C. Accuracy of Emergency Medicine Residents Using Point-of-Care Ultrasound (POCUS) to Detect Retained Stingray Barbs. J Emerg Med 2023; 65:e542-e550. [PMID: 37891068 DOI: 10.1016/j.jemermed.2023.07.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2023] [Revised: 06/21/2023] [Accepted: 07/15/2023] [Indexed: 10/29/2023]
Abstract
BACKGROUND Stingray envenomation is a common presenting complaint for coastal emergency departments in the United States. Currently, radiograph is the gold standard to evaluate for a retained stingray barb, but ultrasound may be a useful tool to detect retained barbs. OBJECTIVE To determine if emergency medicine residents could use ultrasound to identify stingray barbs embedded in animal tissue models. A secondary objective was to determine if resident experience affected their ability to detect stingray barbs. METHODS Thirty-two emergency medicine residents participated in the study. After a short didactic session on foreign body identification with ultrasound, they rotated through six simulation stations and were asked to identify whether a stingray barb was present in pig and chicken tissue models. They were given 2 min per model to identify the presence, size, and depth of a stingray barb. Pre- and postexperiment surveys were collected to assess the residents' level of experience and confidence regarding foreign body identification using ultrasound. RESULTS Residents accurately identified barbs in chicken drumsticks with a sensitivity of 72.92% (95% confidence interval [CI] 63.89-81.48) and a specificity of 64.58% (95% CI 54.16-74.08), and in pig's feet with a sensitivity of 50.00% (95% CI 39.62-60.38) and specificity of 68.75% (95% CI 58.48-77.82). There was no statistically significant difference regarding accuracy for any outcome measured based on experience or level of training. CONCLUSIONS The use of point-of-care ultrasound by novice sonographers lacks sensitivity to identify retained stingray barbs in animal models and is not significantly impacted by resident experience with point-of-care ultrasound.
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Affiliation(s)
- S Russ Richardson
- Department of Emergency Medicine, Grand Strand Medical Center, Myrtle Beach, South Carolina
| | - Jacob Pope
- Department of Emergency Medicine, Grand Strand Medical Center, Myrtle Beach, South Carolina
| | - Lexus Dickson
- University of South Carolina School of Medicine, Columbia, South Carolina
| | | | - Casey Wilson
- Department of Emergency Medicine, Grand Strand Medical Center, Myrtle Beach, South Carolina; University of South Carolina School of Medicine, Columbia, South Carolina
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3
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Niset A, Baert J, Dupriez F. Point-of-Care Ultrasound for the Diagnosis of Pediatric Foreign Body Ingestion: A Narrative Review and Illustrative Case Report. Pediatr Emerg Care 2023; 39:728-733. [PMID: 37339160 DOI: 10.1097/pec.0000000000002997] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/22/2023]
Abstract
PURPOSE Foreign body ingestion (FBI) is a frequent concern in emergency departments. Clinical guidelines recommend performing plain x-rays as the primary modality of diagnosis. Although point-of-care ultrasound (PoCUS) has increasingly been integrated into the daily practice of emergency medicine, it has been poorly investigated in the diagnostic approach for FBI.This review aims to highlight the current state of PoCUS use for pediatric FBI.The following research question was considered in this narrative review: Is PoCUS useful for FBI management? METHODS A literature search was conducted to identify articles reporting PoCUS use for the management of FBI. All articles were assessed for quality by 2 reviewers. MAIN RESULTS The 14 selected articles reported 52 FBI cases in which PoCUS successfully identified and located the ingested FB. Point-of-care ultrasound was used either as the primary imaging technique or after positive or negative x-ray findings. In 5 cases (9.6%), PoCUS was the only modality used for the diagnosis. Of these cases, 3 (60%) underwent a successful procedure to remove the FB and 2 (40%) received conservative treatment without complications. CONCLUSIONS This review suggests that PoCUS might be a reliable modality for the initial management of FBI. PoCUS can locate, identify, and evaluate the size of the FB in a wide range of materials and gastrointestinal locations. Point-of-care ultrasound could eventually become the go-to modality in the case of radiolucent FB, thus avoiding the use of radiation. Further studies are nevertheless required to validate PoCUS use for FBI management.
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Affiliation(s)
- Alexandre Niset
- From the Emergency Department, Cliniques Universitaires Saint-Luc, Brussels, Belgium
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4
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Joat RR, Dhok A, Mitra K, Phatak S, Wattamwar GK. An Aberrant Case of Foreign Body Granuloma in the Left Forearm Due to an Impacted Piece of Glass Bangle. Cureus 2023; 15:e40925. [PMID: 37496526 PMCID: PMC10367940 DOI: 10.7759/cureus.40925] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/25/2023] [Indexed: 07/28/2023] Open
Abstract
Foreign body granuloma is an inflammatory tissue reaction around retained foreign bodies after penetrating trauma. The granulomatous reaction is a natural mechanism of the body to heal wounds by restricting the damage done by a pathological agent and containing the pathological agent to the wound site only. Here we present a classic case of a foreign body granuloma on the dorsal aspect of the forearm. This case was evaluated radiologically on high-frequency ultrasound and X-ray imagining and was operated on afterward. A piece of broken glass bangle was found inside the granuloma.
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Affiliation(s)
- Rohit R Joat
- Radiology, NKP Salve Institute of Medical Sciences, Lata Mangeshkar Hospital, Nagpur, IND
| | - Avinash Dhok
- Radiology, NKP Salve Institute of Medical Sciences, Lata Mangeshkar Hospital, Nagpur, IND
| | - Kajal Mitra
- Radiology, NKP Salve Institute of Medical Sciences, Lata Mangeshkar Hospital, Nagpur, IND
| | - Suresh Phatak
- Radiology, NKP Salve Institute of Medical Sciences, Lata Mangeshkar Hospital, Nagpur, IND
| | - Gajanan K Wattamwar
- Radiology, NKP Salve Institute of Medical Sciences, Lata Mangeshkar Hospital, Nagpur, IND
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5
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Jalili J, Ghane MB, Azari M, Jafarizadeh A, Azari M, Falahatian M, Alihosseini S. Ultrasound-guided interventional approach to intraperitoneal nail gun injury: A case report with literature review. Clin Case Rep 2023; 11:e7195. [PMID: 37064734 PMCID: PMC10090946 DOI: 10.1002/ccr3.7195] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2022] [Revised: 03/06/2023] [Accepted: 03/27/2023] [Indexed: 04/18/2023] Open
Abstract
Literature review suggests that surgery is the only option for dealing with intraperitoneal foreign bodies (laparoscopy and laparotomy). We showed that an interventional method using ultrasound guidance could be considered alongside surgical options.
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Affiliation(s)
- Javad Jalili
- Medical Radiation Sciences Research GroupTabriz University of Medical SciencesTabrizIran
- Department of Radiology, Emam Reza HospitalTabriz University of Medical SciencesTabrizIran
| | - Milad Babazadeh Ghane
- Medical Radiation Sciences Research GroupTabriz University of Medical SciencesTabrizIran
| | - Morteza Azari
- Student Research CommitteeTabriz University of Medical SciencesTabrizIran
| | - Ali Jafarizadeh
- Student Research CommitteeTabriz University of Medical SciencesTabrizIran
| | - Mojtaba Azari
- Student Research CommitteeTabriz University of Medical SciencesTabrizIran
| | - Masih Falahatian
- Medical Radiation Sciences Research GroupTabriz University of Medical SciencesTabrizIran
| | - Samin Alihosseini
- Medical Radiation Sciences Research GroupTabriz University of Medical SciencesTabrizIran
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6
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Goh SLL, Steen C, Wong E, Scott M. Small bowel obstruction secondary to a plastic bezoar. BMJ Case Rep 2022; 15:15/11/e251438. [PMID: 36446472 PMCID: PMC9710328 DOI: 10.1136/bcr-2022-251438] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/03/2022] Open
Abstract
We present a case of a small bowel obstruction secondary to a rare plastic bezoar. A man in their early 20s with autism and an intellectual disability presented with symptoms of small bowel obstruction. CT revealed very subtle signs and, despite passage of gastrografin, ongoing clinical suspicion led to operative management which confirmed the diagnoses of plastic bezoar.
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Affiliation(s)
| | | | - Enoch Wong
- General Surgery, Eastern Health, Box Hill, Victoria, Australia
| | - Monique Scott
- Department of Pscyhology, Swinburne University of Technology, Hawthorn, Victoria, Australia
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7
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Spinnato P, Patel DB, Di Carlo M, Bartoloni A, Cevolani L, Matcuk GR, Crombé A. Imaging of Musculoskeletal Soft-Tissue Infections in Clinical Practice: A Comprehensive Updated Review. Microorganisms 2022; 10. [PMID: 36557582 DOI: 10.3390/microorganisms10122329] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2022] [Revised: 11/19/2022] [Accepted: 11/22/2022] [Indexed: 11/27/2022] Open
Abstract
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.
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8
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Stark M, Matzon JL. Cephalic Vein Intravascular Foreign Body After a Penetrating Injury: A Case Report. JBJS Case Connect 2022; 12:01709767-202212000-00019. [PMID: 36820849 DOI: 10.2106/jbjs.cc.22.00497] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2022] [Accepted: 09/07/2022] [Indexed: 06/18/2023]
Abstract
CASE A 65-year-old man presented with a right forearm metallic foreign body after a projectile injury while using a table saw. The area in question appeared infected prompting a surgical incision and drainage. In the operating room, the metallic foreign body was noted to be entirely intravascular within the lumen of the cephalic vein. It was ultimately removed, and the patient recovered without complication. CONCLUSION Although foreign bodies after traumatic injury are common, it is exceedingly rare to encounter an intravascular foreign body. However, the consequences of proximal migration can be devastating and thus should be in the differential diagnosis for all treating surgeons.
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Affiliation(s)
- Michael Stark
- Division of Orthopaedic Surgery, Rowan University, Stratford, New Jersey
| | - Jonas L Matzon
- Department of Orthopaedic Surgery, Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, Pennsylvania
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9
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Pan P. Ultrasound-Guided Percutaneous Removal of Soft-Tissue Foreign Bodies in Children. J Indian Assoc Pediatr Surg 2021; 26:436-438. [PMID: 34912143 PMCID: PMC8637979 DOI: 10.4103/jiaps.jiaps_192_20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2020] [Revised: 07/21/2020] [Accepted: 08/21/2020] [Indexed: 11/20/2022] Open
Abstract
The aim of the study was to determine the effectiveness and complications of ultrasound (US)-guided percutaneous removal of foreign bodies (FBs). Eleven patients were evaluated for US-guided percutaneous removal of FBs in the upper and lower extremities between April 2018 and March 2020 at the pediatric surgery department of a tertiary-level referral hospital. Elongated FBs, without damage to the adjacent neural and vascular tissue, were included. FBs with open wound, those with glass piece, and irregular-shaped and very superficial palpable FBs were excluded.
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Affiliation(s)
- Pradyumna Pan
- Pediatric Surgery Unit, Ashish Hospital and Research Centre, Jabalpur, Madhya Pradesh, India
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10
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Abstract
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.
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11
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White RZ, Rezaian P, Parasuramar A, Sampson MJ. Ultrasound-assisted foreign body extraction (U-SAFE): Review of technique and technical pearls. J Med Imaging Radiat Oncol 2021; 66:362-369. [PMID: 34396705 DOI: 10.1111/1754-9485.13313] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2021] [Accepted: 08/03/2021] [Indexed: 11/29/2022]
Abstract
INTRODUCTION Soft tissue foreign bodies are a common presentation to emergency departments and primary care. They have variable presentations and associated morbidity depending on their acuity, location, functional impairment and neurovascular involvement. Traditional removal has utilised blind technique or surgical exploration. Their removal can be difficult secondary to induration, inflammation, granulation and scar tissue. Ultrasonography has emerged as a minimally invasive and inexpensive method of examination and retrieval. This article entails ultrasound-guided foreign body extraction with associated pearls of experience. METHODS From March 2017 to August 2020, a fellowship trained interventional radiologist and a fellowship trained musculoskeletal radiologist performed 52 foreign body extractions under ultrasound guidance at a single institution. RESULTS 52 foreign body extractions occurred over 3-year time period with a 95% success rate. The most common location of foreign body was the finger (62%) and feet/toes (17%). Foreign bodies identified include wood (31%), plant-based material (29%), metal (17%), glass (17%) and synthetic material (6%). Two unsuccessful cases were secondary to delayed presentation with significant foreign body reaction and the 2nd due to patient psychiatric issues. There were no identified complications. CONCLUSION Ultrasonography-guided foreign body extraction is a minimally invasive, efficient and targeted technique for foreign body removal.
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Affiliation(s)
- Roland Z White
- Royal Adelaide Hospital, Adelaide, South Australia, Australia.,School of Medicine, The University of Adelaide, Adelaide, South Australia, Australia
| | - Pouria Rezaian
- Royal Adelaide Hospital, Adelaide, South Australia, Australia.,Benson Radiology, Adelaide, South Australia, Australia
| | | | - Matthew J Sampson
- Benson Radiology, Adelaide, South Australia, Australia.,School of Medicine, Flinders University, Adelaide, South Australia, Australia
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12
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Abstract
Point-of-care ultrasound can improve efficacy and safety of pediatric procedures performed in the emergency department. This article reviews ultrasound guidance for the following pediatric emergency medicine procedures: soft tissue (abscess incision and drainage, foreign body identification and removal, and peritonsillar abscess drainage), musculoskeletal and neurologic (hip arthrocentesis, peripheral nerve blocks, and lumbar puncture), vascular access (peripheral intravenous access and central line placement), and critical care (endotracheal tube placement, pericardiocentesis, thoracentesis, and paracentesis). By incorporating ultrasound, emergency physicians caring for pediatric patients have the potential to enhance their procedural scope, confidence, safety, and success.
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Affiliation(s)
- Ashkon Shaahinfar
- Division of Emergency Medicine, UCSF Benioff Children's Hospital Oakland, Trailer 3, 747 52nd Street, Oakland, CA 94609, USA; Department of Emergency Medicine, UCSF School of Medicine, 550 16th Street, MH5552, San Francisco, CA, USA.
| | - Zahra M Ghazi-Askar
- Department of Emergency Medicine, Stanford School of Medicine, 300 Pasteur Drive, Room M121, Alway Building MC 5768, Stanford, CA 94305, USA
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13
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Akkus G, Karagun B, Çetinalp NE, Açıkalın A, Evran M, Sengöz S, Sert M, Zorludemir S, Tetiker T. Clinical Relevance and Immunohistochemical Patterns of Silent Pituitary Adenomas: 10 Years of Single-centre Experience. Curr Med Imaging 2021; 17:310-317. [PMID: 33357196 DOI: 10.2174/1573405616666201223125642] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2020] [Revised: 11/11/2020] [Accepted: 11/13/2020] [Indexed: 11/22/2022]
Abstract
BACKGROUND Silent pituitary adenomas are clinically non-functional (i.e., without clinically evident pituitary hormone production). INTRODUCTION The aim of this study was to investigate subjects with silent pituitary adenomas for possible variations in their clinical status. METHODS A total of 102 patients who had undergone surgery for pituitary adenoma and had been diagnosed with silent pituitary adenoma was included in the study. The patients' preoperative and postoperative hormonal parameters and magnetic resonance imaging (MRI) features were collected, and pathological specimens were re-evaluated. RESULTS Immunohistochemistry results of the 102 patients were as follows: hormone-negative adenomas (n=35) 35.5%; FSH+LH-positivity (n=32) 31.3%; ACTH-positivity (n=11) 10.7%; α-subunit- positivity (n= 9) 8.8%; prolactin-positivity (n=8) 7.8%; GH-positivity (n=6) 5.4%; and plurihormonal adenoma (n=1). The mean sizes of SGA, SGHA, and SCA were 28.0±12.7, 30.0±16.0, and 27.7±8.9mm (p>0.05), respectively. With the exception of silent gonadotroph adenomas (SGAs), female gender dominance was shown in patients with silent growth hormone adenoma (SGHA) and silent corticotroph adenoma (SCA). Although no clinical relevance was observed in relation to hormonal excess, preoperative GH (4.21±4.6, vs. 0.27±0.36 p=0.00) was slightly more elevated in SGHA than in GH-negative adenomas. Additionally, preoperative basal ACTH values (47.3±28.7 vs. 23.9±14.4, p=0.003) were also higher in SCA compared to the other types. Our findings revealed SCAs to be of more aggressive behaviour than SGHAs and SGAs due to invasiveness in radiological imaging, their elevated re-operation, and postoperative ACTH values. CONCLUSION Silent pituitary adenomas represent a challenging diagnostic tumour group. Careful initial evaluation of patients with pituitary adenomas should consider any mild signs and symptoms of functionality, particularly in cases of GH- and ACTH-secreting adenomas.
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Affiliation(s)
- Gamze Akkus
- Cukurova University, Faculty of Medicine, Division of Endocrinology, Adana, Turkey
| | - Barış Karagun
- Cukurova University, Faculty of Medicine, Division of Endocrinology, Adana, Turkey
| | - Nuri E Çetinalp
- Cukurova University, Faculty of Medicine, Division of Neurosurgery, Adana, Turkey
| | - Arbil Açıkalın
- Cukurova University, Faculty of Medicine, Divison of Pathology, Adana, Turkey
| | - Mehtap Evran
- Cukurova University, Faculty of Medicine, Division of Endocrinology, Adana, Turkey
| | - Sinem Sengöz
- Cukurova University, Faculty of Medicine, Division of Endocrinology, Adana, Turkey
| | - Murat Sert
- Cukurova University, Faculty of Medicine, Division of Endocrinology, Adana, Turkey
| | - Suzan Zorludemir
- Cukurova University, Faculty of Medicine, Divison of Pathology, Adana, Turkey
| | - Tamer Tetiker
- Cukurova University, Faculty of Medicine, Division of Endocrinology, Adana, Turkey
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14
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Abstract
Complete visualization of lesions is critical for the accurate diagnosis and
management of dermatological diseases. Currently, the most readily available
technologies used by dermatologists include dermoscopy and photography.
Nevertheless, ultrasound has emerged as a useful non-invasive modality in
dermatology, which can be added to the clinical examination supporting an early
and more accurate diagnosis. Moreover, there are significant technological
advances in recent years, such as the development of handheld devices and
ultra-high frequency probes that have expanded the integration of ultrasound
into daily dermatology practice. In this article, we reviewed the most common
applications of ultrasound in the field of dermatology.
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Affiliation(s)
- Nouf Almuhanna
- 793831507 Division of Dermatology, Department of Medicine, University of Toronto, Toronto, ON, Canada.,Division of Dermatology, Department of Medicine, Sunnybrook Health Sciences Centre, Toronto, ON, Canada.,Division of Dermatology, Department of Medicine, King Fahad Medical City, Riyadh, Saudi Arabia
| | - Ximena Wortsman
- 14655 Institute for Diagnostic Imaging and Research of the Skin and Soft Tissues, Santiago, Chile.,38103 Department of Dermatology, Faculty of Medicine, Universidad de Chile, Santiago, Chile.,Department of Dermatology, Faculty of Medicine, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Iris Wohlmuth-Wieser
- 793831507 Division of Dermatology, Department of Medicine, University of Toronto, Toronto, ON, Canada.,Division of Dermatology, Department of Medicine, Sunnybrook Health Sciences Centre, Toronto, ON, Canada.,Department of Dermatology, University Hospital of the Paracelsus Medical University, Salzburg, Austria
| | | | - Raed Alhusayen
- 793831507 Division of Dermatology, Department of Medicine, University of Toronto, Toronto, ON, Canada.,Division of Dermatology, Department of Medicine, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
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15
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Frier J, Nicholas E, Klawitter P. Case Report: Using Point-of-care Ultrasound as a Tool to Identify a Urethral Foreign Body. Clin Pract Cases Emerg Med 2021; 5:39-42. [PMID: 33560949 PMCID: PMC7872595 DOI: 10.5811/cpcem.2020.10.49290] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2020] [Accepted: 10/09/2020] [Indexed: 11/11/2022] Open
Abstract
Introduction When patients present to the emergency department with retained urethral foreign objects, imaging is crucial for identifying and further describing the object(s). Imaging is also important to plan the management and to assess the potential complications of foreign object removal. Ultrasonography is sometimes used for this purpose and can often provide more information on the object and its location and characteristics than plain radiographs. Case Report This case report discusses the identification and characterization of a retained urethral foreign object that was not seen on plain radiography. Conclusion While ultrasonography has its own limitations, in the cases of retained foreign objects, it can provide preferable imaging and can help guide the management of these patients.
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Affiliation(s)
- Jacob Frier
- SUNY Upstate Medical University, Department of Emergency Medicine, Syracuse, New York
| | - Elizabeth Nicholas
- SUNY Upstate Medical University, Department of Emergency Medicine, Syracuse, New York
| | - Paul Klawitter
- SUNY Upstate Medical University, Department of Emergency Medicine, Syracuse, New York
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16
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Athanaselis ED, Fyllos A, Stefanou N, Varitimidis SE, Giannikas D. A Tumor-Like Lump in the Palm Caused by an Inconspicuous-for 75 Years-Bullet. Case Rep Orthop 2020; 2020:1-3. [PMID: 32695542 PMCID: PMC7368181 DOI: 10.1155/2020/8898016] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2020] [Revised: 06/23/2020] [Accepted: 06/26/2020] [Indexed: 11/18/2022] Open
Abstract
Case. An unusual case of a foreign body in the hand is described here. Excision of a tumor-like soft tissue mass revealed a 75-year-old World War II bullet fragment of which patient was unaware. Conclusion. Differential diagnosis of hand lumps and inflammatory reaction must always include retained foreign bodies even after a very long period of posttraumatic quiescence or patient’s inability to provide a relative injury case history.
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17
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Rodríguez Bandera AI, Sebaratnam DF, Feito Rodríguez M, de Lucas Laguna R. Cutaneous ultrasound and its utility in pediatric dermatology. Part I: Lumps, bumps, and inflammatory conditions. Pediatr Dermatol 2020; 37:29-39. [PMID: 31743485 DOI: 10.1111/pde.14033] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
High-frequency ultrasonography represents a promising tool for pediatric dermatologists. It is a non-invasive diagnostic technique that is particularly appealing when working with children. It can be easily performed at the patient's bedside, avoiding diagnostic delays, sedation, or multiple visits. It represents a useful adjunct to clinical examination and can enhance our understanding of cutaneous diseases. Patient cooperation and limited training and experience are the main challenges for cutaneous ultrasonography in pediatric dermatology. This review describes cutaneous ultrasonography and the nuances of its use in the pediatric setting, followed by the ultrasonographic findings of cutaneous lumps, bumps, and inflammatory dermatoses commonly encountered in pediatric patients.
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Affiliation(s)
| | - Deshan Frank Sebaratnam
- Sydney Children's Hospitals' Network, Sydney, NSW, Australia.,University of New South Wales, Sydney, NSW, Australia
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18
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Abstract
BACKGROUND Ultrasonography is a cost-effective, noninvasive, and expedient imaging modality with numerous clinical applications. Conventional ultrasound uses transducers with frequencies that range from 5 to 12 MHz. However, ultrahigh frequency ultrasound (UHFUS) is capable of producing frequencies up to 70 MHz, which can achieve tissue resolution up to 30 μm. The purpose of our study is to present the capabilities of a novel technology and to describe its possible clinical applications for hand surgery. METHODS The Vevo 2100 (VisualSonics, Toronto, Canada) system was used to perform all ultrasound exams. Four unique linear array transducers were employed. All studies were performed by the authors, who have no formal training in ultrasound techniques, on 5 healthy resident volunteers and 1 clinical patient under institutional review board approval. RESULTS A series of 10 static images per participant and dynamic, real-time videos were obtained at various locations within the hand and wrist. UHFUS is capable of quickly and reliably imaging larger structures such as foreign bodies, soft tissue masses, and the flexor tendons, and diagnosing an array of pathologies within these structures. In addition, UHFUS can identify much finer structures such as the intimal layer of the arteries in the hand and individual fascicles within the digital nerves to provide data about vessel quality and vascular and neural pathologies. CONCLUSIONS UHFUS is a novel technology that shows multiple advantages over conventional ultrasound for imaging the fine superficial structures of the hand and wrist, and can be deployed by the surgeon at the point of care.
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Affiliation(s)
| | | | - Jonathan D. Keith
- Rutgers New Jersey Medical School,
Newark, USA,Jonathan D. Keith, Division of Plastic
Surgery, Department of Surgery, Rutgers New Jersey Medical School, 140 Bergen
Street, Suite E1620, Newark, NJ 07103, USA.
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Huttin C, Diaz JJH, Vernet P, Facca S, Igeta Y, Liverneaux P. Relevance of intraoperative ultrasound imaging for detecting foreign bodies in the hand: A series of 19 cases. Hand Surg Rehabil 2018; 37:363-367. [PMID: 30348518 DOI: 10.1016/j.hansur.2018.05.008] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/18/2018] [Revised: 05/08/2018] [Accepted: 05/31/2018] [Indexed: 11/17/2022]
Abstract
Radiolucent foreign bodies of the hand are frequent and may lead to pain, infection, hematoma and/or migration. Their diagnosis and removal can be difficult. The goal of this study was to assess the usefulness of intraoperative ultrasound imaging for detecting translucent foreign bodies in the hand to facilitate their removal. Our single-center retrospective study included 19 patients with preoperatively radiolucent but echogenic foreign bodies. An intraoperative ultrasound was performed to assist with and confirm the removal of the foreign body. The foreign bodies were vegetal in 15 cases, made of glass in 2 cases, rock in 1 case and undetermined in 1 case. The average length was 4.65 mm (min 1, max 16) and the average width 1.02 mm. All foreign bodies were visible during the intraoperative ultrasound and were no longer visible after their removal. Because intraoperative ultrasound imaging was able to guide the removal of all radiolucent foreign bodies in our study, it can be a useful tool for the removal of radiolucent foreign bodies.
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Affiliation(s)
- C Huttin
- Department of hand surgery, SOS main, CCOM, university hospital of Strasbourg, FMTS, University of Strasbourg, Icube CNRS 7357, 10, avenue Baumann, 67400 Illkirch, France
| | - J J Hidalgo Diaz
- Department of hand surgery, SOS main, CCOM, university hospital of Strasbourg, FMTS, University of Strasbourg, Icube CNRS 7357, 10, avenue Baumann, 67400 Illkirch, France
| | - P Vernet
- Department of hand surgery, SOS main, CCOM, university hospital of Strasbourg, FMTS, University of Strasbourg, Icube CNRS 7357, 10, avenue Baumann, 67400 Illkirch, France
| | - S Facca
- Department of hand surgery, SOS main, CCOM, university hospital of Strasbourg, FMTS, University of Strasbourg, Icube CNRS 7357, 10, avenue Baumann, 67400 Illkirch, France
| | - Y Igeta
- Department of hand surgery, SOS main, CCOM, university hospital of Strasbourg, FMTS, University of Strasbourg, Icube CNRS 7357, 10, avenue Baumann, 67400 Illkirch, France; Department of orthopedic surgery, Juntendo university, Bunkyō, Tokyo, Japan
| | - P Liverneaux
- Department of hand surgery, SOS main, CCOM, university hospital of Strasbourg, FMTS, University of Strasbourg, Icube CNRS 7357, 10, avenue Baumann, 67400 Illkirch, France.
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20
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Braig EM, Birnbacher L, Schaff F, Gromann L, Fingerle A, Herzen J, Rummeny E, Noël P, Pfeiffer F, Muenzel D. Simultaneous wood and metal particle detection on dark-field radiography. Eur Radiol Exp 2018; 2:1. [PMID: 29708215 PMCID: PMC5909361 DOI: 10.1186/s41747-017-0034-1] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2017] [Accepted: 11/28/2017] [Indexed: 11/23/2022] Open
Abstract
Background Currently, the detection of retained wood is a frequent but challenging task in emergency care. The purpose of this study is to demonstrate improved foreign-body detection with the novel approach of preclinical X-ray dark-field radiography. Methods At a preclinical dark-field x-ray radiography, setup resolution and sensitivity for simultaneous detection of wooden and metallic particles have been evaluated in a phantom study. A clinical setting has been simulated with a formalin fixated human hand where different typical foreign-body materials have been inserted. Signal-to-noise ratios (SNR) have been determined for all test objects. Results On the phantom, the SNR value for wood in the dark-field channel was strongly improved by a factor 6 compared to conventional radiography and even compared to the SNR of an aluminium structure of the same size in conventional radiography. Splinters of wood < 300 μm in diameter were clearly detected on the dark-field radiography. Dark-field radiography of the formalin-fixated human hand showed a clear signal for wooden particles that could not be identified on conventional radiography. Conclusions x-ray dark-field radiography enables the simultaneous detection of wooden and metallic particles in the extremities. It has the potential to improve and simplify the current state-of-the-art foreign-body detection.
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Affiliation(s)
- Eva-Maria Braig
- 1Chair of Biomedical Physics, Department of Physics and Munich School of BioEngineering, Technical University of Munich, James-Franck-Str. 1, 85748 Garching, Germany.,2Department of Diagnostic and Interventional Radiology, Klinikum rechts der Isar, Technical University of Munich, Ismaninger Straße 22, 81675 München, Germany
| | - Lorenz Birnbacher
- 1Chair of Biomedical Physics, Department of Physics and Munich School of BioEngineering, Technical University of Munich, James-Franck-Str. 1, 85748 Garching, Germany
| | - Florian Schaff
- 1Chair of Biomedical Physics, Department of Physics and Munich School of BioEngineering, Technical University of Munich, James-Franck-Str. 1, 85748 Garching, Germany
| | - Lukas Gromann
- 1Chair of Biomedical Physics, Department of Physics and Munich School of BioEngineering, Technical University of Munich, James-Franck-Str. 1, 85748 Garching, Germany
| | - Alexander Fingerle
- 2Department of Diagnostic and Interventional Radiology, Klinikum rechts der Isar, Technical University of Munich, Ismaninger Straße 22, 81675 München, Germany
| | - Julia Herzen
- 1Chair of Biomedical Physics, Department of Physics and Munich School of BioEngineering, Technical University of Munich, James-Franck-Str. 1, 85748 Garching, Germany
| | - Ernst Rummeny
- 2Department of Diagnostic and Interventional Radiology, Klinikum rechts der Isar, Technical University of Munich, Ismaninger Straße 22, 81675 München, Germany
| | - Peter Noël
- 1Chair of Biomedical Physics, Department of Physics and Munich School of BioEngineering, Technical University of Munich, James-Franck-Str. 1, 85748 Garching, Germany.,2Department of Diagnostic and Interventional Radiology, Klinikum rechts der Isar, Technical University of Munich, Ismaninger Straße 22, 81675 München, Germany
| | - Franz Pfeiffer
- 1Chair of Biomedical Physics, Department of Physics and Munich School of BioEngineering, Technical University of Munich, James-Franck-Str. 1, 85748 Garching, Germany.,2Department of Diagnostic and Interventional Radiology, Klinikum rechts der Isar, Technical University of Munich, Ismaninger Straße 22, 81675 München, Germany.,3Institute for Advanced Study, Technical University of Munich, 85748 Garching, Germany
| | - Daniela Muenzel
- 2Department of Diagnostic and Interventional Radiology, Klinikum rechts der Isar, Technical University of Munich, Ismaninger Straße 22, 81675 München, Germany
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Yang X, Sun L, Ye J, Li X, Tao R. Ultrasonography in Detection of Vaginal Foreign Bodies in Girls: A Retrospective Study. J Pediatr Adolesc Gynecol 2017; 30:620-5. [PMID: 28669787 DOI: 10.1016/j.jpag.2017.06.008] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2017] [Revised: 06/20/2017] [Accepted: 06/27/2017] [Indexed: 11/20/2022]
Abstract
STUDY OBJECTIVE In this study we investigated the sonographic features of vaginal foreign bodies in girls and the diagnostic role of combined transperineal and transabdominal ultrasonography in the detection of vaginal foreign bodies in this population. DESIGN, SETTING, PARTICIPANTS, INTERVENTIONS, AND MAIN OUTCOME MEASURES: A retrospective review of the records of 249 girls seen in the outpatient pediatric and adolescent gynecology clinic of our hospital and referred to our department for sonographic evaluation of suspected vaginal foreign bodies between 2013 and 2016 was performed. All patients were transperineally and transabdominally scanned using an ultrasound machine with 3-MHz and 7.5-MHz transducers. The sonographic features of the detected foreign bodies were recorded and reported. All patients also underwent pelvic radiography. The presence of foreign bodies was confirmed using vaginoscopy. RESULTS Two hundred forty-nine patients were included in this study, and vaginal foreign bodies were detected in 181 patients. Vaginal foreign bodies often present in girls aged from 2 to 12 years old. The most common vaginal foreign bodies were toilet paper, beads, small parts of toys, cap of water color brush, and crayons. The overall sensitivity, specificity, positive and negative predictive values of transperineal/transabdominal sonography in the diagnosis of vaginal foreign bodies were 81%, 53%, 82%, and 51%, respectively. The sensitivity, specificity, and positive and negative predictive values of transabdominal sonography were 33%, 49%, 63%, and 21%, respectively. The sensitivity, specificity, and positive and negative predictive values of transperineal sonography were 64%, 49%, 77%, and 33%, respectively. Abnormal findings were detected using x-ray in only 43 of the 181 cases (23.7%). The sensitivity, specificity, and positive and negative predictive values of x-ray were 24%, 91%, 88%, and 31%, respectively. The size of the foreign bodies ranged from 2 mm to 35 mm. For foreign bodies larger than 5 mm, the rate of sonographic accuracy reached 100%. For foreign bodies smaller than 5 mm, 32 false positive results, and 34 false negative results were identified. One hundred thirty-nine of 181 foreign bodies were less than 2 cm from the vaginal orifice (77%). All foreign bodies were hyperechoic compared with adjacent tissues. Some vaginal foreign bodies had characteristic echo patterns. With the exception of 1 patient with a detained AAA battery that caused vaginal ulceration, the other patients had a full recovery. CONCLUSION Vaginal foreign bodies were hyperechoic compared with adjacent tissues and often had characteristic echo patterns. The use of combined transperineal and transabdominal ultrasonography might be helpful in diagnosing foreign bodies, especially when the size of the foreign body is larger than 5 mm. Therefore, ultrasonography might be preferred for the initial evaluation of suspected vaginal foreign bodies, because it is a noninvasive, radiation-free, and inexpensive technique.
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Abstract
RATIONALE Retained foreign body (FB) in soft tissues of children is commonly encountered in the emergency room. The FBs include different kinds of material and associate with some nonspecific symptoms. They usually penetrate the skin or other soft tissues and show some entry holes. PATIENT A 4-month-old male infant was admitted to our department due to the edema on the right of scrotum, higher skin temperature, and a funicular lump with serious haphalgesia in the right groin and scrotum. DIAGNOSES Imaging studies revealed a foreign body in right spermatic cord. A surgical exploration was performed, and a hair was dislodged. The pathological diagnosis was hyperplastic fibrous connective tissue and inflammatory reaction. INTERVENTIONS A surgical exploration was performed to dislodge the foreign body. OUTCOMES The boy had an uneventful course after the surgery and was discharged from the hospital one week later. The incision healed well when the boy came back for follow-up one week later. LESSONS We still have no idea that how this FB got to the soft tissue. Few previous studies can be retrieved to help us. But we can learn that foreign body should be one of consideration for the origin of inflammation or infection of soft tissues even there is not any laceration and penetration injuries.
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Affiliation(s)
| | - Jin Zhang
- Pediatrics, Qingdao Women and Children's Hospital, Liaoyang Road
| | | | - Li Zhang
- Department of Pathology, The Affiliated Hospital of Qingdao University, Jiangsu Road, Qingdao, China
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Lulla A, Whitman T, Amii R, Chiem AT. Role of Ultrasound in the Identification of Longitudinal Axis in Soft-Tissue Foreign Body Extraction. West J Emerg Med 2016; 17:819-821. [PMID: 27833698 PMCID: PMC5102617 DOI: 10.5811/westjem.2016.8.30988] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2016] [Revised: 08/15/2016] [Accepted: 08/25/2016] [Indexed: 11/14/2022] Open
Abstract
Identification and retrieval of soft-tissue foreign bodies (STFB) poses significant challenges in the emergency department. Prior studies have demonstrated the utility of ultrasound (US) in identification and retrieval of STFBs, including radiolucent objects such as wood. We present a case of STFB extraction that uses US to identify the longitudinal axis of the object. With the longitudinal axis identified, the foreign body can be excised by making an incision where the foreign body is closest to the skin. The importance of this technique as it pertains to minimizing surrounding tissue destruction and discomfort for patients has not been previously reported.
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Affiliation(s)
- Al Lulla
- Olive View-UCLA Medical Center, Department of Emergency Medicine, Sylmar, California
| | - Taryn Whitman
- California State University, Los Angeles, Department of Biological Sciences, Los Angeles, California
| | - Ricky Amii
- Olive View-UCLA Medical Center, Department of Emergency Medicine, Sylmar, California
| | - Alan T Chiem
- Olive View-UCLA Medical Center, Department of Emergency Medicine, Sylmar, California
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Abstract
Ultrasonography facilitates dynamic, real-time evaluation of bones, joints, tendons, nerves, and vessels, making it an ideal imaging modality for hand and wrist conditions. Ultrasonography can depict masses and fluid collections, help locate radiolucent foreign bodies, characterize traumatic or overuse tendon or ligament pathology, and help evaluate compressive peripheral neuropathy and microvascular blood flow. Additionally, this modality improves the accuracy of therapeutic intra-articular or peritendinous injections and facilitates aspiration of fluid collections, such as ganglia.
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Abstract
Patients commonly present to the emergency department with a suspected retained foreign body, following penetrating injury. While plain radiography is often the first line in identifying radio-opaque foreign bodies, radiolucent foreign bodies such as wood and plastic can easily be missed. Furthermore, real-time visualization of such a foreign body can assist in its removal. This article evaluates the use of point-of-care ultrasound by emergency physicians in the identification and removal of soft-tissue foreign bodies along with describing the appropriate technique and highlighting the potential pitfalls. An illustrated case example is presented that highlights the benefits of point-of-care ultrasound foreign body detection and guided removal.
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Affiliation(s)
- David Lewis
- Department of Emergency Medicine, Dalhousie University, Saint John, New Brunswick, Canada; Discipline of Emergency Medicine, Memorial University, Saint John, New Brunswick, Canada; Department of Emergency Medicine, Horizon Health Network, Saint John, New Brunswick, Canada
| | - Aman Jivraj
- Department of Diagnostic Imaging, Queen Elizabeth II Health Sciences Centre, Halifax, Nova Scotia, Canada
| | - Paul Atkinson
- Department of Emergency Medicine, Dalhousie University, Saint John, New Brunswick, Canada; Discipline of Emergency Medicine, Memorial University, Saint John, New Brunswick, Canada; Department of Emergency Medicine, Horizon Health Network, Saint John, New Brunswick, Canada
| | - Robert Jarman
- Department of Emergency Medicine, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle, United Kingdom
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Abstract
A retrospective review was conducted to determine the effect sonography has in localizing these foreign bodies. Patients selected for this study included all cases in which sonography was performed and demonstrated the presence or assisted in the removal of FB. After review of the records, 20 patients fit this selection criterion. Seventeen of the 20 patients had radiographs performed, in which only 8 of the 17 were positive for FB. Sonography demonstrated all FB in 19 of 20. In 11 of 20 patients, sonographic imaging directly guided their removal. Sonography can be an invaluable tool in finding and localizing for removal soft tissue foreign bodies.
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Wieschhoff GG, Sheehan SE, Wortman JR, Dyer GSM, Sodickson AD, Patel KI, Khurana B. Traumatic Finger Injuries: What the Orthopedic Surgeon Wants to Know. Radiographics 2016; 36:1106-28. [DOI: 10.1148/rg.2016150216] [Citation(s) in RCA: 49] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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28
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Park HJ, Lee SM, Lee SY, Son ES, Chung EC, Rho MH, Lee SJ. Ultrasound-Guided Percutaneous Removal of Wooden Foreign Bodies in the Extremities with Hydro-Dissection Technique. Korean J Radiol 2015; 16:1326-31. [PMID: 26576123 PMCID: PMC4644755 DOI: 10.3348/kjr.2015.16.6.1326] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2015] [Accepted: 08/19/2015] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE We described the technique of ultrasound (US)-guided percutaneous removal of the foreign bodies (FB) with hydro-dissection in the radiologic department and presented video files of several cases. MATERIALS AND METHODS Four patients referred to the radiology department for US evaluation and US-guided percutaneous removal of the FBs in the upper and lower extremities between November, 2006 and November, 2013 were included in this study. The procedures started with US evaluation for the exact location and shape of the FB. A 5 mm-sized skin incision was made at the site of the nearest point from the FB where no passing arteries or tendons were present. We adopted a hydrodissection technique to separate the FB from adjacent tissue using a 2% lidocaine solution. Injected anesthetics detached the FBs from surrounding tissue and thereby facilitated removal. After the tip of the mosquito forceps reached the FB, the wooden FBs were removed. RESULTS The mean time required for the entire procedure was approximately 20 minutes. There were no significant complications during the US-guided removal or long-term complications after the procedure. All 4 FBs were successfully removed from the soft tissue under US guidance. CONCLUSION Ultrasound-guided percutaneous removal of the FBs with hydro-dissection in the radiology department is a less invasive and safe method over surgical removal in the operating room. Additionally, the use of a guide wire and serial dilator may help minimize soft tissue injury and facilitate the introduction of forceps.
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Affiliation(s)
- Hee Jin Park
- Department of Radiology, Sungkyunkwan University School of Medicine, Kangbuk Samsung Hospital, Seoul 03181, Korea
| | - Sung Moon Lee
- Department of Radiology, Dongsan Medical Center, Keimyung University School of Medicine, Daegu 41931, Korea
| | - So Yeon Lee
- Department of Radiology, Sungkyunkwan University School of Medicine, Kangbuk Samsung Hospital, Seoul 03181, Korea
| | - Eun Seok Son
- Department of Orthopaedic Surgery, Dongsan Medical Center, Keimyung University School of Medicine, Daegu 41931, Korea
| | - Eun Chul Chung
- Department of Radiology, Sungkyunkwan University School of Medicine, Kangbuk Samsung Hospital, Seoul 03181, Korea
| | - Myung Ho Rho
- Department of Radiology, Sungkyunkwan University School of Medicine, Kangbuk Samsung Hospital, Seoul 03181, Korea
| | - Sun Joo Lee
- Department of Radiology, Inje University College of Medicine, Busan Paik Hospital, Busan 47392, Korea
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Seol SH, Cho J, Lee WJ, Choi SC. Use of a slit-lamp microscope for treating impacted facial foreign bodies in the emergency department. Clin Exp Emerg Med 2015; 2:188-192. [PMID: 27752596 PMCID: PMC5052844 DOI: 10.15441/ceem.14.048] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2014] [Revised: 12/12/2014] [Accepted: 12/29/2014] [Indexed: 11/23/2022] Open
Abstract
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.
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Davis J, Czerniski B, Au A, Adhikari S, Farrell I, Fields JM. Diagnostic Accuracy of Ultrasonography in Retained Soft Tissue Foreign Bodies: A Systematic Review and Meta-analysis. Acad Emerg Med 2015; 22:777-87. [PMID: 26111545 DOI: 10.1111/acem.12714] [Citation(s) in RCA: 46] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2014] [Revised: 01/27/2015] [Accepted: 01/29/2015] [Indexed: 11/26/2022]
Abstract
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.
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Affiliation(s)
- Joshua Davis
- Sidney Kimmel Medical College; Thomas Jefferson University; Philadelphia PA
| | - Byron Czerniski
- Sidney Kimmel Medical College; Thomas Jefferson University; Philadelphia PA
| | - Arthur Au
- Department of Emergency Medicine; Thomas Jefferson University; Philadelphia PA
| | - Srikar Adhikari
- Department of Emergency Medicine; University of Arizona; Tucson AZ
| | - Isaac Farrell
- Department of Emergency Medicine; University of Arizona; Tucson AZ
| | - J. Matthew Fields
- Department of Emergency Medicine; Thomas Jefferson University; Philadelphia PA
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Affiliation(s)
- Harlan M Starr
- The Curtis National Hand Center, MedStar Union Memorial Hospital, Baltimore, MD; MedStar Orthopaedics and Sports Medicine, Ellicott City, MD
| | - Matthew D Sedgley
- The Curtis National Hand Center, MedStar Union Memorial Hospital, Baltimore, MD; MedStar Orthopaedics and Sports Medicine, Ellicott City, MD
| | - Michael S Murphy
- The Curtis National Hand Center, MedStar Union Memorial Hospital, Baltimore, MD; MedStar Orthopaedics and Sports Medicine, Ellicott City, MD.
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Budhram GR, Schmunk JC. Bedside Ultrasound Aids Identification and Removal of Cutaneous Foreign Bodies: A Case Series. J Emerg Med 2014; 47:e43-8. [DOI: 10.1016/j.jemermed.2014.01.033] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2013] [Accepted: 01/31/2014] [Indexed: 10/25/2022]
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Jarraya M, Hayashi D, de Villiers RV, Roemer FW, Murakami AM, Cossi A, Guermazi A. Multimodality Imaging of Foreign Bodies of the Musculoskeletal System. AJR Am J Roentgenol 2014; 203:W92-W102. [DOI: 10.2214/ajr.13.11743] [Citation(s) in RCA: 47] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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Lee WW, Kim DJ. Migrating Sternal Rod: Ultrasound Identification of an Unusual Soft Tissue Foreign Body. J Emerg Med 2014; 46:e117-20. [DOI: 10.1016/j.jemermed.2013.11.072] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2013] [Revised: 10/07/2013] [Accepted: 11/16/2013] [Indexed: 11/24/2022]
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Strickland CD, Auckland AK, Payne WT. Surgical implications of preoperative sonographic localization of sea urchin spine foreign bodies. J Ultrasound Med 2014; 33:181-183. [PMID: 24371116 DOI: 10.7863/ultra.33.1.181] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
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Tirado A, Wu T, Noble VE, Huang C, Lewiss RE, Martin JA, Murphy MC, Sivitz A, Cohen SG. Ultrasound-guided procedures in the emergency department-diagnostic and therapeutic asset. Emerg Med Clin North Am 2013; 31:117-49. [PMID: 23200331 DOI: 10.1016/j.emc.2012.09.009] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
Bedside ultrasound is an extremely valuable and rapidly accessible diagnostic and therapeutic modality in potentially life- and limb-threatening situations in the emergency department. In this report, the authors discuss the role of ultrasound in quick assessment of pathologic conditions and its use to aid in diagnostic and therapeutic interventions.
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Acar MA, Kerimoğlu Ü, Karalezli N, Güleç A. Ultrasound for the Detection of Retained Plastic and Undetected Metallic Foreign Bodies in the Foot. ELECTRON J GEN MED 2012. [DOI: 10.29333/ejgm/82444] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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Abstract
Traditionally performed by a small group of highly trained specialists, bedside sonographic procedures involving the musculoskeletal system are often delayed despite the critical need for timely diagnosis and treatment. Due to this limitation, a need evolved for more portability and accessibility to allow performance of emergent musculoskeletal procedures by adequately trained non-radiology personnel. The emergence of ultrasound-assisted bedside techniques and increased availability of portable sonography provided such an opportunity in select clinical scenarios. This review summarizes the current literature describing common ultrasound-based musculoskeletal procedures. In-depth discussion of each ultrasound procedure including pertinent technical details, indications and contraindications is provided. Despite the limited amount of prospective, randomized data in this area, a substantial body of observational and retrospective evidence suggests potential benefits from the use of musculoskeletal bedside sonography.
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Affiliation(s)
- Nelson A Royall
- Nelson A Royall, David P Bahner, Department of Emergency Medicine, The Ohio State University Medical Center, Columbus, OH 43210, United States
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41
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Borgohain B, Borgohain N, Handique A, Gogoi PJ. Case report and brief review of literature on sonographic detection of accidentally implanted wooden foreign body causing persistent sinus. Crit Ultrasound J 2012; 4:10. [PMID: 22871025 PMCID: PMC3495023 DOI: 10.1186/2036-7902-4-10] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2012] [Accepted: 05/16/2012] [Indexed: 11/17/2022] Open
Abstract
Despite advances in imaging techniques, the detection of vegetative foreign bodies in soft tissues remains a difficult and sometimes even a challenging task. Clinical evaluation of such patient may present several months or even years after the initial injury and clinician may fail to elicit an antecedent skin puncture. X-ray examination will miss radiolucent foreign bodies. A 15-year-old boy presented with a draining non-healing sinus at the lateral aspect of his right thigh for 9 months. Musculoskeletal ultrasonography was ordered after ruling out chronic osteomyelitis to detect possible lesions around the thigh. High-frequency linear ultrasonic probe readily detected an elongated foreign body within the vastus lateralis muscle. A long piece of wood was confirmed at surgery. Non-healing sinus with normal finding in radiograph following old trauma should raise the suspicion of implanted radiolucent foreign body/bodies. The role of diagnostic ultrasound as a valuable screening tool for the detection of foreign body is briefly reviewed.
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Affiliation(s)
- Bhaskar Borgohain
- Department of Orthopaedics & Trauma, North Eastern Indira Gandhi Regional Institute of Health and Medical Sciences (NEIGRIHMS), Shillong, 793018, India.
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Abstract
Traditionally performed by a small group of highly trained specialists, bedside sonographic procedures involving the musculoskeletal system are often delayed despite the critical need for timely diagnosis and treatment. Due to this limitation, a need evolved for more portability and accessibility to allow performance of emergent musculoskeletal procedures by adequately trained non-radiology personnel. The emergence of ultrasound-assisted bedside techniques and increased availability of portable sonography provided such an opportunity in select clinical scenarios. This review summarizes the current literature describing common ultrasound-based musculoskeletal procedures. In-depth discussion of each ultrasound procedure including pertinent technical details, indications and contraindications is provided. Despite the limited amount of prospective, randomized data in this area, a substantial body of observational and retrospective evidence suggests potential benefits from the use of musculoskeletal bedside sonography.
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Royall NA, Farrin E, Bahner DP, Stawicki SP. Ultrasound-assisted musculoskeletal procedures: A practical overview of current literature. World J Orthop 2011; 2:57-66. [PMID: 22474637 PMCID: PMC3302042 DOI: 10.5312/wjo.v2.i7] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2011] [Revised: 06/28/2011] [Accepted: 07/05/2011] [Indexed: 02/06/2023] Open
Abstract
Traditionally performed by a small group of highly trained specialists, bedside sonographic procedures involving the musculoskeletal system are often delayed despite the critical need for timely diagnosis and treatment. Due to this limitation, a need evolved for more portability and accessibility to allow performance of emergent musculoskeletal procedures by adequately trained non-radiology personnel. The emergence of ultrasound-assisted bedside techniques and increased availability of portable sonography provided such an opportunity in select clinical scenarios. This review summarizes the current literature describing common ultrasound-based musculoskeletal procedures. In-depth discussion of each ultrasound procedure including pertinent technical details, indications and contraindications is provided. Despite the limited amount of prospective, randomized data in this area, a substantial body of observational and retrospective evidence suggests potential benefits from the use of musculoskeletal bedside sonography.
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Affiliation(s)
- Nelson A Royall
- Nelson A Royall, David P Bahner, Department of Emergency Medicine, The Ohio State University Medical Center, Columbus, OH 43210, United States
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Said HG, Masoud MA, Yousef HA, Imam HM. Multidetector CT for thorn (wooden) foreign bodies of the knee. Knee Surg Sports Traumatol Arthrosc 2011; 19:823-5. [PMID: 20953763 DOI: 10.1007/s00167-010-1283-1] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/13/2010] [Accepted: 09/16/2010] [Indexed: 11/30/2022]
Abstract
PURPOSE Thorn (wooden) foreign bodies of the knee present a challenge in their diagnosis. Partly because of inaccurate history and sometimes a long duration of symptoms, radiographs are negative and MRI may show synovitis without a specific pathology. METHODS We report a case of a 16-year-old male patient with a date palm thorn foreign body, which caused septic arthritis. He underwent two open surgeries. Both failed to detect the loose body. An MRI of the knee showed a high signal in the posterolateral compartment; however, the pathology could not be confirmed except by 64 Multidetector CT (MDCT) that clearly identified the thorn and its location. RESULTS Arthroscopic removal and synovectomy were done by a 4-portal technique. The patient went on to complete recovery. CONCLUSION Multidetector CT has proven very useful in identifying wooden foreign bodies, their size and location.
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Affiliation(s)
- Hatem G Said
- Arthroscopy Unit, Orthopedic Department, Assiut University Hospital, PO Box 110, Assiut, 71111, Egypt
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Sidharthan S, Mbako AN. Pitfalls in diagnosis and problems in extraction of retained wooden foreign bodies in the foot. Foot Ankle Surg 2010; 16:e18-20. [PMID: 20483120 DOI: 10.1016/j.fas.2009.04.006] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2009] [Revised: 04/08/2009] [Accepted: 04/14/2009] [Indexed: 02/04/2023]
Abstract
The detection and removal of a radiolucent foreign body in soft tissues is a problem. It is further complicated when it is not radio-opaque and embedded in the deep layers of the foot. Despite advances in imaging techniques, the detection of retained wooden foreign bodies remains a difficult and challenging task. Although radiographs have been proven to be ineffective, it is often the first method used. Wood often splinters, causing incomplete removal and persistent symptoms. In such cases complete surgical extraction cannot be guaranteed in spite of our best efforts. Therefore, a post-procedure imaging to ensure the adequacy of extraction becomes crucial. The choice of imaging in such circumstances is a moot point to consider. This case report highlights the common pitfalls associated with retained wooden foreign bodies and demonstrates how ultrasonography could be used as a simple and effective tool in this regard.
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Affiliation(s)
- Sujith Sidharthan
- Department of Trauma & Orthopaedics, Maelor Hospital, Croesnewydd Road, Wrexham, North Wales, LL13 7TD, United Kingdom.
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Saboo SS, Saboo SH, Soni SS, Adhane V. High-resolution sonography is effective in detection of soft tissue foreign bodies: experience from a rural Indian center. J Ultrasound Med 2009; 28:1245-1249. [PMID: 19710224 DOI: 10.7863/jum.2009.28.9.1245] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/28/2023]
Abstract
OBJECTIVE Patients with penetrating trauma or field injuries are commonly encountered by emergency physicians. Clinical examination by inspection or palpation can detect superficial foreign bodies (FBs), and radiographs can detect radiopaque FBs. However, soft tissue FBs can be easily missed. The aim of our series was to evaluate the role of high-resolution sonography in detection of soft tissue FBs. METHODS All patients referred to our center for sonographic evaluation of suspected soft tissue FBs from 1999 to 2008 were included in this analysis. Patients were scanned with an ultrasound machine using a 7.5-MHz transducer. The suspected area was scanned in both axial and sagittal planes. The nature of the FB, length, and depth from the surface were recorded and reported. The presence of an FB was confirmed by surgical excision. RESULTS During the study period, 123 patients underwent sonography for a suspected FB, of which 12 were lost to follow-up and excluded from the analysis. The study group included 73.8% male patients; the mean age was 36.2 years. Wood fragments and wooden thorns were the most frequently observed FBs, at 46.2% and 36.2%, respectively. The surgeon was satisfied with the reported depth of the FB from the surface in most cases (89%). The overall sensitivity and specificity of sonography were 94.5% and 53.8%. CONCLUSIONS High-resolution sonography is a very sensitive tool in diagnosis of soft tissue FBs. It also helps the surgeon with accurate localization, permitting easy removal.
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Affiliation(s)
- Sanjiv Bajaj
- Mallinckrodt Institute of Radiology, Washington University in St Louis, St Louis, MO, USA.
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Huang BK, Hubeny CM, Dogra VS. Sonographic appearance of a retained tunneled catheter cuff causing a foreign body reaction. J Ultrasound Med 2009; 28:245-248. [PMID: 19168774 DOI: 10.7863/jum.2009.28.2.245] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/27/2023]
Affiliation(s)
- Brady K Huang
- Department of Imaging Sciences, University of Rochester Medical Center, Rochester, NY 14642, USA
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Callegari L, Leonardi A, Bini A, Sabato C, Nicotera P, Spano’ E, Mariani D, Genovese EA, Fugazzola C. Ultrasound-guided removal of foreign bodies: personal experience. Eur Radiol 2009; 19:1273-9. [DOI: 10.1007/s00330-008-1266-5] [Citation(s) in RCA: 43] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2008] [Revised: 11/10/2008] [Accepted: 11/28/2008] [Indexed: 10/21/2022]
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Crystal CS, Masneri DA, Hellums JS, Kaylor DW, Young SE, Miller MA, Levsky ME. Bedside ultrasound for the detection of soft tissue foreign bodies: a cadaveric study. J Emerg Med 2008; 36:377-80. [PMID: 18930374 DOI: 10.1016/j.jemermed.2007.10.071] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2006] [Revised: 04/17/2007] [Accepted: 10/31/2007] [Indexed: 12/18/2022]
Abstract
The objective of this study was to evaluate the sensitivity and specificity of bedside ultrasound, as performed by emergency physicians with typical equipment, in detecting small, soft tissue foreign bodies, using a cadaveric model. This was a prospective study, using 6 unembalmed human cadavers and 6 ultrasound-credentialed, emergency medicine residency-trained physicians as sonographers. Incisions were made in 150 total sites of the extremities and each site was randomly assigned one of five groups: wood, metal, plastic, glass, or no foreign body. All foreign bodies were 2.5 mm3 in total volume or less, no longer than 5 mm in any dimension, and inserted to a depth of up to 3 cm. Ultrasound was performed with a SonoSite TITAN (SonoSite, Inc., Bothell, WA) ultrasound system using a L38/10-5 broadband linear array transducer. Sonographers were blinded to the number, type, and location of foreign bodies. A total of 900 ultrasound examinations were recorded. Overall sensitivity of ultrasound for foreign body detection was 52.6% (95% confidence interval [CI] 48.9%-56.2%), and overall specificity was 47.2% (95% CI 39.9%-54.5%). Positive predictive value was 79.9% (95% CI 76.3%-83.5%), and negative predictive value was 20.0% (95% CI 16.2%-23.7%). Sensitivity for individual sonographers ranged from 40.8% to 72.3% (average 52.6% +/- 13.3%), and specificity ranged from 30% to 66.7% (average 47.2% +/- 15.1%). Inter-observer reliability was poor. In our model, bedside ultrasound performed by emergency physicians was neither sensitive nor specific for the presence of small soft tissue foreign bodies.
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Affiliation(s)
- Chad S Crystal
- Department of Emergency Medicine, Carl R. Darnall Army Medical Center, Fort Hood, Texas, USA
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