Foreign Bodies in the Skin: Evaluation and Management

 

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 recommendationEvidence ratingComments

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 recommendationEvidence ratingComments

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.

Evaluation and Localization

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

show all author info

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

show all references

1. Rui P, Kang K, Ashman JJ. National Hospital Ambulatory Medical Care Survey: 2016 emergency department summary tables. 2016. Accessed September 11, 2019. https://www.cdc.gov/nchs/data/nhamcs/web_tables/2016_ed_web_tables.pdf...

2. Fowler GC. Foreign body removal from skin and soft tissue. In: Pfenninger JL, Fowler GC, eds. Pfenninger & Fowler’s Procedures for Primary Care. 3rd ed. Elsevier; 2014:135–140.

3. Anderson MA, Newmeyer WL III, Kilgore ES Jr. Diagnosis and treatment of retained foreign bodies in the hand. Am J Surg. 1982;144(1):63–67.

4. Avner JR, Baker MD. Lacerations involving glass. The role of routine roentgenograms. Am J Dis Child. 1992;146(5):600–602.

5. American College of Radiology. Radiation dose to adults from common imaging examinations. Accessed September 11, 2019. https://www.acr.org/-/media/ACR/Files/Radiology-Safety/Radiation-Safety/Dose-Reference-Card.pdf

6. Ingraham CR, Mannelli L, Robinson JD, et al. Radiology of foreign bodies: how do we image them? Emerg Radiol. 2015;22(4):425–430.

7. Stone DB, Scordino DJ. Foreign body removal. In: Roberts JR, Custalow CB, Thomsen TW, et al., eds. Roberts and Hedges’ Clinical Procedures in Emergency Medicine and Acute Care. 7th ed. Elsevier; 2019:708–737.

8. Aras MH, Miloglu O, Barutcugil C, et al. Comparison of the sensitivity for detecting foreign bodies among conventional plain radiography, computed tomography and ultrasonography. Dentomaxillofac Radiol. 2010;39(2):72–78.

9. Hiremath R, Reddy H, Ibrahim J, et al. Soft tissue foreign body: utility of high resolution ultrasonography. J Clin Diagn Res. 2017;11(7):TC14–TC16.

10. Lulla A, Whitman T, Amii R, et al. Role of ultrasound in the identification of longitudinal axis in soft-tissue foreign body extraction. West J Emerg Med. 2016;17(6):819–821.

11. Blankenship RB, Baker T. Imaging modalities in wounds and superficial skin infections. Emerg Med Clin North Am. 2007;25(1):223–234.

12. Jarraya M, Hayashi D, de Villiers RV, et al. Multimodality imaging of foreign bodies of the musculoskeletal system. AJR Am J Roentgenol. 2014;203(1):W92–W102.

13. He B, Xu C, Mao Y, et al. A novel navigation system to guide metallic foreign body extraction. Int J Comput Assist Radiol Surg. 2016;11(11):2105–2110.

14. RP summary: recommended practices for care of patients undergoing pneumatic tourniquet-assisted procedures. AORN J. 2013;98(4):397–400.

15. Ilicki J. Safety of epinephrine in digital nerve blocks: a literature review. J Emerg Med. 2015;49(5):799–809.

16. Sonthalia S, Jha AK, Kaliyadan F. Dermoscopy for the detection and safe extraction of an intracutaneous foreign body. J Am Acad Dermatol. 2018;79(2):e19–e20.

17. Halaas GW. Management of foreign bodies in the skin. Am Fam Physician. 2007;76(5):683–690. Accessed January 24, 2020. https://www.aafp.org/afp/2007/0901/p683.html

18. Fernandez R, Griffiths R. Water for wound cleansing. Cochrane Database Syst Rev. 2012;(2):CD003861.

19. Atiyeh BS, Dibo SA, Hayek SN. Wound cleansing, topical antiseptics and wound healing. Int Wound J. 2009;6(6):420–430.

20. Edlich RF, Rodeheaver GT, Thacker JG, et al. Revolutionary advances in the management of traumatic wounds in the emergency department during the last 40 years: part I. J Emerg Med. 2010;38(1):40–50.

21. Quinn JV, Polevoi SK, Kohn MA. Traumatic lacerations: what are the risks for infection and has the ‘golden period’ of laceration care disappeared? Emerg Med J. 2014;31(2):96–100.

22. Peterson AS. “The “golden period” for wound repair. J Lancaster Gen Hospital. 2010;5(4):134–135. Accessed May 7, 2019. https://bit.ly/2Ue5oD9

23. Kiwanuka E, Hsieh S, Roussel LO, et al. The use of a magnetic port finder in the retrieval of air rifle BBs to the upper extremity. J Hand Surg Am. 2018;43(11):1043.e1–1043.e3.

24. Su Y, Nan G. Using methylene blue as a marker to find and remove tiny metallic foreign bodies embedded in the soft tissues of children: a randomised controlled trial. Int J Surg. 2016;29:43–48.

25. Wu CS, Chen W, Fu TY, et al. Magnet hanging on the skin - an easy method to detect occult metallic cutaneous foreign body. J Eur Acad Dermatol Venereol. 2016;30(10):e36–e37.

26. Aldrich NZ, Brodell RT. Confirmation of cutaneous metallic foreign bodies with a magnet. Arch Dermatol. 2011;147(5):623–624.

27. Sarıhan A, Can C. Soft tissue foreign body removal with magnet in ED settings. Am J Emerg Med. 2014;32(8):952.e3–952.e5.

28. Gammons M, Jackson E. Fishhook removal. Am Fam Physician. 2001;63(11):2231–2237. Accessed January 24, 2020. https://www.aafp.org/afp/2001/0601/p2231.html

29. Doser C, Cooper WL, Ediger WM, et al. Fishhook injuries: a prospective evaluation. Am J Emerg Med. 1991;9(5):413–415.

30. Prats M, O’Connell M, Wellock A, et al. Fishhook removal: case reports and a review of the literature. J Emerg Med. 2013;44(6):e375–e380.

31. Dieter RA Jr, Whitehouse LR, Gulliver R. Cactus spine wounds: a case report and short review of the literature. Wounds. 2017;29(2):E18–E21.

32. Capellan O, Hollander JE. Management of lacerations in the emergency department. Emerg Med Clin North Am. 2003;21(1):205–231.

33. Vrints I, Den Hondt M, Van Brussel M, et al. Immediate debridement of road rash injuries with Versajet® hydrosurgery: traumatic tattoo prevention? Aesthetic Plast Surg. 2014;38(2):467–470.

34. Jeon H, Geronemus RG. Successful treatment of a traumatic tattoo in a pediatric patient using a 755-nm picosecond laser. Pediatr Dermatol. 2018;35(6):e430–e431.

35. Diaz JH, Lopez FA. Skin, soft tissue and systemic bacterial infections following aquatic injuries and exposures. Am J Med Sci. 2015;349(3):269–275.

36. Cummings P, Del Beccaro MA. Antibiotics to prevent infection of simple wounds: a meta-analysis of randomized studies. Am J Emerg Med. 1995;13(4):396–400.

37. Moran GJ, Talan DA, Abrahamian FM. Antimicrobial prophylaxis for wounds and procedures in the emergency department. Infect Dis Clin North Am. 2008;22(1):117–143.

38. Stevens DL, Bisno AL, Chambers HF, et al. Practice guidelines for the diagnosis and management of skin and soft tissue infections: 2014 update by the Infectious Diseases Society of America. Clin Infect Dis. 2014;59(2):147–159.

39. Fisher MC, Goldsmith JF, Gilligan PH. Sneakers as a source of Pseudomonas aeruginosa in children with osteomyelitis following puncture wounds. J Pediatr. 1985;106(4):607–609.

40. Liang JL, Tiwari T, Moro P, et al. Prevention of pertussis, tetanus, and diphtheria with vaccines in the United States: Recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR Recomm Rep. 2018;67(2):1–44.

 

 

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