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Am Fam Physician. 2004;69(11):2525-2528

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.

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.

Email letter submissions to afplet@aafp.org. Letters should be fewer than 400 words and limited to six references, one table or figure, and three authors. Letters submitted for publication in AFP must not be submitted to any other publication. Letters may be edited to meet style and space requirements.

This series is coordinated by Kenny Lin, MD, MPH, deputy editor.

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