Letters to the Editor

Subungual Slivers May Be Treated Conservatively

to the editor: In the June 15, 2003, issue of American Family Physician, Drs. Chan and Salam discuss an operative technique for the removal of subungual slivers.1 I would like to suggest an alternative method, which is to treat the patient conservatively. If the physician cannot remove the sliver easily with an approach under the nail (i.e., using a hooked needle or forceps), the sliver may be left where it is. The patient should receive tetanus toxoid and antibiotics, if necessary. The sliver will gradually "grow" out with the nail and can be removed easily in 10 to 14 days.

In 20 years of using this technique, I have never seen a subsequent deformity or infection of the nail. The patient is happier with the results because he or she does not have a "split" nail while the débrided nail heals. The initial pain seems to clear rapidly and can be handled with analgesic medications.

ROBERT KAYE, M.D.
Samaritan North Lincoln Hospital Clinic
825 N.W. Hwy. 101
Lincoln City, OR 97367

REFERENCE

1. Chan C, Salam GA. Splinter removal. Am Fam Physician 2003;67:2557-62.

Removing Splinters Should Be A Very Simple Procedure

to the editor: In the article, "Splinter Removal,"1 Drs. Chan and Salam advocate rather extensive surgical exposure to remove all splinters. While I am not an expert on splinter removal, I have removed hundreds of them during my 20-year medical career. My practice has been simply to expose the end of the splinter and pull it out in the direction in which it entered. I cannot remember a single case in which I later found that a fragment had been retained. I wonder what evidence the authors have for recommending such extensive surgical exposure for removing splinters. Their suggested technique seems unnecessarily invasive.

While on the subject of splinter removal, I would also like to share the following two practice pearls concerning splinters: (1) Mammography is the ideal soft tissue imaging technique to show a radiolucent splinter. This technique has worked nicely for me on multiple occasions; and (2) a No-scalpel dissecting forceps is the ideal instrument to remove a splinter. Its sharp tips can be used to easily dilate the splinter entrance wound and simultaneously grasp the splinter itself. I always use this instrument when confronting a patient with a splinter.

RONALD D. REYNOLDS, M.D.
1050 Old U.S. Hwy. 52
New Richmond, OH 45157

REFERENCE

1. Chan C, Salam GA. Splinter removal. Am Fam Physician 2003;67:2557-62.

in reply: We welcome the response to our article.1 There are numerous approaches to removing a splinter. Most physicians have a considerable amount of experience with this common issue and use their own preferred techniques for splinter removal. Unfortunately, no controlled studies have been done comparing these different techniques, leaving physicians to rely on anecdotal experiences.

When dealing with a splinter, the patient's symptoms, severity of tissue reaction, and the composition, size, and location of the foreign body are important factors to consider.2,3 Very small splinters, particularly the ones composed of nonreactive material, may not need to be removed and can be managed conservatively. If the foreign body is large, made of reactive material, or results in significant discomfort and tissue reaction, it must be promptly and completely removed.2,3 The techniques recommended in our article1 may appear extensive, but they ensure complete removal of the splinter.2,4 I have removed a large number of superficial horizontal splinters by simply de-roofing the skin over the splinter with an 18-gauge needle. This technique results in only minimal tissue disruption while enabling me to visualize the entire extent of the splinter.4

Dr. Reynolds' point of using mammography for the detection of radiolucent foreign bodies is well taken. Although I do not have any personal experience using mammography for this purpose, I have found high-resolution ultrasound to be a reliable and cost-effective means of detecting radiolucent foreign bodies embedded in subcutaneous soft tissues.

Subungual splinters, if large or composed of reactive material, often result in significant discomfort and should be removed completely.2,3,5 The nail, which has been cut to expose the splinter, usually grows back in a few weeks (fingernails grow at a rate of approximately 0.1 mm per day). I have not seen a single nail deformity resulting from this procedure. Permanent nail deformity in this setting would result only if the germinal matrix or lunula (which is located near the proximal end of the nail) is disturbed-a situation that must be avoided.

GOHAR A. SALAM, M.D., D.O.
North Shore University Hospital
300 Community Dr.
Manhasset, NY 11021

REFERENCES

1. Chan C, Salam GA. Splinter removal. Am Fam Physician 2003;67:2557-62.

2. Stone DB, Koutouzis TK. Foreign body removal. In: Roberts JR, Hedges JR, eds. Clinical procedures in emergency medicine. 4th ed. Philadelphia: Saunders, 2004:694-716.

3. Pons PT. Foreign bodies. In: Rosen P, ed. Emergency medicine: concepts and clinical practice. 4th ed. St. Louis: Mosby, 1998:861-77.

4. Buttaravoli PM, Stair TO. Minor emergencies: splinters to fractures. St. Louis: Mosby, 2000;471-7.

5. Miller MA, Brodell RT. Surgical pearl: treatment of subungual splinters. J Am Acad Dermatol 1995;33: 667-8.

Bupropion Should Be Included in Article on Antidepressants

to the editor: Although the article1 by Drs. Ables and Baughman in the February 1, 2003, issue of American Family Physician seemed to be a comprehensive review of antidepressant agents, it did not mention bupropion (Wellbutrin). This agent is novel because it is a norepinephrine and dopamine reuptake inhibitor. It has the same efficacy as any selective serotonin reuptake inhibitor (SSRI) for the treatment of depression and has characteristically different side effects. It does not have the sexual dysfunction and gastrointestinal side effects associated with SSRIs. However, it can cause sleeplessness, agitation, and vivid dreams.2 Also, it is not associated with weight gain, while patients receiving SSRIs tend to gain weight. Bupropion (such as Zyban) also is indicated for smoking cessation.3 It is particularly useful for patients who are depressed and attempting to quit smoking.

CRAIG M. WAX, D.O.
info@HealthIsNumberOne.com
53 South Main St.
Mullica Hill, NJ 08062

REFERENCES

1. Ables AZ, Baughman OL 3d. Antidepressants: update on new agents and indications. Am Fam Physician 2003;67:547-54.

2. Bupropion (Wellbutrin XL). Package insert. Philadelphia: GlaxoSmith-Kline 2003. Accessed March 11, 2004 at: http://us.gsk.com/products/assets/us_wellbutrinxl.pdf.

3. Bupropion (Zyban). Package insert. Philadelphia: GlaxoSmith-Kline 2003. Accessed March 11, 2004 at: http://us.gsk.com/products/assets/us_zyban.pdf.

in reply: I would like to thank Dr. Wax for his comments. Our article1 was not meant to be a comprehensive review. We were asked to provide an update on new agents and/or indications. Bupropion has been on the market since 1985 and, hopefully, physicians are aware of its advantages in the treatment of depression.

ADRIENNE Z. ABLES, Pharm.D.
Spartanburg Family Medicine Residency Program
835 N. Church St., Suite 510
Spartanburg, SC 29303

REFERENCE

1. Ables AZ, Baughman OL 3d. Antidepressants: update on new agents and indications. Am Fam Physician 2003;67:547-54.

Send letters to Jay Siwek, M.D., Editor, American Family Physician, 11400 Tomahawk Creek Pkwy., Leawood, KS 66211-2672; fax: 913-906-6080; e-mail: afplet@aafp.org. Please include your complete address, telephone number, and fax number. Letters should be submitted on disk, double-spaced, fewer than 500 words, and limited to one table or figure and six references. Please submit a word count. Letters submitted for publication in AFP must not be submitted to any other publication. Possible conflicts of interest must be disclosed at time of submission. Submission of a letter will be construed as granting the AAFP permission to publish the letter in any of its publications in any form. The editors may edit letters to meet style and space requirements.