Foreign Bodies in the Skin: Evaluation and Management

Jedda Rupert; James David Honeycutt; Michael Ryan Odom

Jun 15, 2020 Issue

Foreign Bodies in the Skin: Evaluation and Management

JEDDA RUPERT, MD, and JAMES DAVID HONEYCUTT, MD, Mike O’Callaghan Military Medical Center, Nellis Air Force Base, Nevada

MICHAEL RYAN ODOM, MD, Fort Belvoir Community Hospital, Fort Belvoir, Virginia

Am Fam Physician. 2020 Jun 15;101(12):740-747.

Author disclosure: No relevant financial affiliations.

Foreign bodies may be introduced into the skin through lacerations and soft tissue wounds. Long-term complications of retained foreign bodies include chronic pain and neurovascular impairment. Wound exploration and initial imaging with radiography or ultrasonography should be considered before foreign body removal. Risks and benefits of removal should be discussed with the patient. Although some foreign bodies may be left in place, removal should be considered if the risk of complications is high. A cooperative patient and adequate wound visualization are important for successful foreign body removal. Adequate analgesia and judicious use of anxiolytics and sedation may be helpful. Wound irrigation with normal saline or tap water is recommended after foreign body removal. Antiseptic solutions for wound irrigation may impair healing and should be avoided. Although there is no consensus on the use of antibiotic prophylaxis, several indications exist. The patient’s tetanus immunization history should be reviewed, and vaccine should be administered if indicated.

Soft tissue wounds are common injuries. In 2016, wounds were the primary diagnosis in 6.8 million emergency department visits in the United States.1 Wounds can contain foreign bodies, which may cause long-term complications if inappropriately managed, including neurovascular deficits and chronic pain.

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SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendation	Evidence rating	Comments
Radiography with underpenetration and multiple views should be used to evaluate deep wounds.⁷	C	Expert opinion in the absence of clinical trials
Ultrasonography should be used to localize radiolucent foreign bodies.⁸	C	In-vitro animal study showing improved localization compared with computed tomography and plain radiography
Foreign body wounds should be cleaned with normal saline or tap water.¹⁸	B	Consistent evidence from randomized controlled trials showing no difference in infection rates
Antiseptic solutions should not be used for cleaning foreign body wounds because they slow healing.¹⁹	C	In-vitro studies showing cytotoxicity with several solutions
Antibiotic prophylaxis is not indicated for simple non-bite wounds in immunocompetent patients.³⁶	B	Consistent evidence from randomized controlled trials showing no benefit from treatment
Tetanus immunization history should be reviewed for patients who have wounds with foreign bodies.⁴⁰	C	Expert opinion and consensus guideline in the absence of clinical trials

A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to https://www.aafp.org/afpsort.

SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendation	Evidence rating	Comments
Radiography with underpenetration and multiple views should be used to evaluate deep wounds.⁷	C	Expert opinion in the absence of clinical trials
Ultrasonography should be used to localize radiolucent foreign bodies.⁸	C	In-vitro animal study showing improved localization compared with computed tomography and plain radiography
Foreign body wounds should be cleaned with normal saline or tap water.¹⁸	B	Consistent evidence from randomized controlled trials showing no difference in infection rates
Antiseptic solutions should not be used for cleaning foreign body wounds because they slow healing.¹⁹	C	In-vitro studies showing cytotoxicity with several solutions
Antibiotic prophylaxis is not indicated for simple non-bite wounds in immunocompetent patients.³⁶	B	Consistent evidence from randomized controlled trials showing no benefit from treatment
Tetanus immunization history should be reviewed for patients who have wounds with foreign bodies.⁴⁰	C	Expert opinion and consensus guideline in the absence of clinical trials

Evaluation and Localization

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Abstract
Evaluation and Localization
Indications for Foreign Body Removal
Equipment and Preparation
Foreign Body Removal Techniques
Types of Foreign Bodies
Disposition
References

Patients may not express concern for foreign bodies after an injury. However, the patient history may suggest that further evaluation is needed. The sensation of foreign bodies and trauma secondary to high-velocity projectiles or sharp, fragile objects should increase suspicion for foreign bodies.2 Careful visual inspection is necessary to assess for the presence of foreign bodies. Palpation around wounds may reveal tenderness. Metal instruments may

The Authors

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JEDDA RUPERT, MD, is a faculty physician at Mike O’Callaghan Military Medical Center, Nellis Air Force Base, Nev., and an assistant professor in the Department of Family Medicine at the Uniformed Services University of the Health Sciences, Bethesda, Md....

JAMES DAVID HONEYCUTT, MD, FAAFP, FAWM, is an associate program director at Mike O’Callaghan Military Medical Center and an assistant professor in the Department of Family Medicine at the Uniformed Services University of the Health Sciences.

MICHAEL RYAN ODOM, MD, FAAFP, is a faculty physician at Fort Belvoir (Va.) Community Hospital, and an assistant professor in the Department of Family Medicine at the Uniformed Services University of the Health Sciences.

Address correspondence to Jedda Rupert, MD, 4700 Las Vegas Blvd. N., Bldg. 1300, Nellis AFB, NV 89191 (email: jedda.p.rupert.mil@mail.mil). Reprints are not available from the authors.

Author disclosure: No relevant financial affiliations.

References

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