x
x

FOREIGN BODY and FOREIGN BODY GRANULOMA

Introduction

Retained foreign bodies in the hand and wrist are fairly common occurrences after penetrating and impalement injuries. The hand is the most common site for foreign body implantation.  These types of injuries are one of the most frequent reasons for emergency department (ED) visits. There is no general consensus regarding the most effective treatment approach, but it is generally agreed that some foreign bodies must be surgically removed, while others can remain in place if the patient is asymptomatic, and there is minimal risk for functional impairment or other future complications.1-5

The foreign body granuloma is a fibrous granulomatous mass that forms around a retained foreign body. These masses can be painful, swollen and intermittently inflamed.13,14

Pathophysiology

  • The mechanism of penetrating or impalement injury that may lead to a retained foreign body can include broken objects (eg, such as glass, metal, stone, wood) that may leave embedded fragments; bite injuries or punches to the face and remaining tooth pieces; wounds from nails or other sharp objects that could leave remnants of leather, cloth, rubber, or plastic; high pressure injection injuries; and less common objects like thorns and sea urchin spines6
  • Some foreign bodies are easy to detect or result in direct injury to vital structures; however, 15-38% are overlooked upon initial examination1,7
    • If a foreign body is missed, it may remain asymptomatic for a prolonged period of time or may give rise to a variety of inflammatory, allergic, and/or infectious complications2
    • A retained foreign body can also develop into a foreign body granuloma. 13
    • Staphylococcus aureus is the most common bacteria that causes hand infections in foreign body cases, followed by beta-hemolytic Streptococcus8
  • The foreign body granuloma is a tissue reaction to the retained foreign material.  These chronic lesions are composed of fibrous tissue (collagen), chronic inflammatory cells, large multinucleated giant cells, fibroblasts, plasma cells, and macrophages.14

Related Anatomy

  • Deep spaces of the hand
  • Tendon sheaths
  • Neurovascular bundles
  • Foreign body granuloma
  • Bone erosions and joint damage14

Incidence and Related Conditions

  • Each year, ~11 million people are seen in US EDs for traumatic wounds and lacerations9
    • Nearly one third of these wounds involve the fingers, hand, or wrist, and a retained foreign body is present or strongly suspected in ≥10% of cases.10
    • The risk of puncture wounds and retained foreign bodies increase in warmer seasons and climates due to more exposed bare skin and outdoor recreation.6
    • Individuals who work in occupations such as carpentry and the garment industry are at an increased risk of impalement with nails or pins.6
    • Many individuals who present with a foreign body in the hand or wrist are young, and the risk for various hand injuries tend to decline with increasing age and growing experience.2 
    • Work related injuries are a common cause of retained foreign bodies.14

Differential Diagnosis

  • Hand infection
  • Sebaceous cyst
  • Epidermoid cyst
ICD-10 Codes

  • FOREIGN BODY

    Diagnostic Guide Name

    FOREIGN BODY

    ICD 10 Diagnosis, Single Code, Left Code, Right Code and Bilateral Code

    DIAGNOSISSINGLE CODE ONLYLEFTRIGHTBILATERAL (If Available)
    FOREIGN BODY, SUPERFICIAL, WITHOUT OPEN WOUND    
    - ELBOW S50.352_S50.351_ 
    - FOREARM S50.852_S50.851_ 
    - WRIST S60.852_S50.851_ 
    - HAND S60.552_S60.551_ 
    - INDEX FINGER S60.451_S60.450_ 
    - MIDDLE FINGER S60.453_S60.452_ 
    - RING FINGER S60.455_S60.454_ 
    - LITTLE FINGER S60.457_S60.456_ 
    - THUMB S60.352_S60.351_ 
    FOREIGN BODY, WITH LACERATION    
    - ELBOW S51.022_S51.021_ 
    - FOREARM S51.822_S51.821_ 
    - WRIST S61.522_S61.521_ 
    - HAND S61.422_S61.421_ 
    - INDEX FINGER S61.221_S61.220_ 
    - MIDDLE FINGER S61.223_S61.222_ 
    - RING FINGER S61.225_S61.224_ 
    - LITTLE FINGER S61.227_S61.226_ 
    - THUMB S61.022_S61.021_ 
    FOREIGN BODY, RETAINED/RESIDUAL, SOFT TISSUEM79.5   

    Instructions (ICD 10 CM 2020, U.S. Version)

    THE APPROPRIATE SEVENTH CHARACTER IS TO BE ADDED TO EACH CODE FROM CATEGORY S50, S60, S51 AND S61
    A - Initial Encounter
    D - Subsequent Routine Healing
    S - Sequela

    ICD-10 Reference

    Reproduced from the International statistical classification of diseases and related health problems, 10th revision, Fifth edition, 2016. Geneva, World Health Organization, 2016 https://apps.who.int/iris/handle/10665/246208

Symptoms
History of an injury with a retained object like glass, rock, piece of metal etc.
Pain, swelling, erythema and/or heat
Sensation of foreign body
Palpable mass
Typical History

A 31-year-old left-handed woman got a deep wooden splinter into the palmar side of her left hand when she slipped and fell on an old wooden boardwalk. After the injury, she removed only part of the wooden splinter but believed she had completely dislodged it. In the following weeks, she started noticing pain, swelling, and other signs of inflammation in her left hand.  She also felt as if something was still in her palm when she rubbed it with her fingers. Eventually, these symptoms caused her to seek medical attention.

Positive Tests, Exams or Signs
Work-up Options
Images (X-Ray, MRI, etc.)
  • Retained glass after laceration near base of right index finger
    Retained glass after laceration near base of right index finger
  • Retained FB (pellet) present for 20 years. Note (1) vague soft tissue shadow from granuloma and (2) bony changes in distal phalanx
    Retained FB (pellet) present for 20 years. Note (1) vague soft tissue shadow from granuloma and (2) bony changes in distal phalanx
Treatment Options
Conservative
  • The composition of the foreign body, symptom presentation, degree of contamination, and risk of complications should all influence treatment decisions
    • If a foreign body is producing pain, it should be removed6
    • Metal objects in soft tissue pose a lower risk of infection than organic matter; therefore, inert metal foreign bodies may not have to be removed, as removal may cause more trauma
    • Small glass fragments or small BB pellets may also be left in place when there is no anticipation of functional impairment, no evidence of infection, and the patient is without pain8
  • Symptomatic foreign body granulomas should be surgically excised.
  • Local wound irrigation debridement with dressings and elevation.  Closure depends on the size of the wound and the degree of contamination.  Some wounds should be left open.
    • May be appropriate for patients with relatively nonreactive foreign bodies within the thenar or hypothenar musculature that cause no functional impairment8
  • Antibiotics (eg, dicloxacillin, erythromycin, cephalexin, methicillin, nafcillin) are recommended when there is evidence of an existing infection8
Operative
  • Wound exploration and surgical foreign body removal/extraction
    • Indications
      • A functional abnormality of vasculature, joints, nerves, or tendons
      • Anticipation of progressive injury to an adjacent vessel, nerve, tendon, or joint by mechanical trauma
      • Neurovascular injury
      • Foreign body in the finger unless very tiny
      • History or evidence of significant contamination with injury
      • Tendon laceration
      • Cosmetic deformity
      • Functional impairment
      • Chronic pain
      • Patient with known allergy to foreign body
    • Contraindications
      • Deep embedding or inaccessibility
      • Unacceptable iatrogenic risks to neurovascular structures during retrieval
      • Minute size
      • Inert material
      • Asymptomatic presentation8,12
  • Extensive wide surgical irrigation and debridement is indicated when there is involvement of tendons, tendon sheaths, bone, joints and neurovascular bundles.  Emergency treatment that may be necessary in some cases.  The degree of contamination associated with the foreign body injury should be considered when deciding on the need for surgical debridement. A stick that impales the hand can carry soil contaminants into the deeper tissues, carrying with the contaminants,  bacteria which may cause a resistant infection. Therefore, wounds with heavy soil contamination and a residual foreign body need acute surgical debridement.  The type of anesthesia used should be determined by considering the location of the foreign body, the depth of penetration, the most likely injured structure(s), the age and psychological status of the patient, and the predicted duration of the operation.5
  • When the foreign material is a liquid, particularly when it is injected under high pressure,  the foreign material should be meticulously removed as thoroughly as possible , but no organic solvents should be used to wash out the residual. These solvents are likely to also damage the contaminated tissues.  High pressure injury can inject materials such as paint or hydraulic fluid through a pin hole wound but can spread through the tissues and cause massive soft tissue damage. These injuries require urgent extensive surgical irrigation and debridement.  Despite excellent surgical care there maybe residual damage.  A detailed review of high pressure injection injuries is beyond the scope of its diagnostic guide; however, the paper by Pappou and Deal provides an excellent more extensive discussion of the diagnosis and treatment of the high pressure injection injury.15
Treatment Photos and Diagrams
Surgical Treatment of Foreign Body and associated granuloma
  • Surgical excision of foreign body and associated granuloma (arrow)
    Surgical excision of foreign body and associated granuloma (arrow)
  • Excised pellet (circle) and granuloma (arrow)
    Excised pellet (circle) and granuloma (arrow)
Complications
  • Infection
  • Osteomyelitis
  • Tissue destruction
  • Neurovascular injury
  • Necrosis
  • Tissue distension
  • Thrombosis of compressed digital vessels
  • Amputation
  • Wound enlargement/creation of additional wound
  • Dissection of nearby tissue
  • Loss of range of motion with residual contractures
Outcomes
  • Managing foreign body injuries with acute surgical extraction decreases complications8
  • The highest likelihood for complications is with glass or wood foreign bodies12
    • In a series of 61 cases in which foreign bodies were removed under local or regional/general anesthesia, 16 patients were discharged within a month with wounds that healed normally, with no signs or symptoms to warrant further follow-up. In 27 patients, there were no postoperative complications after 3 months of follow-up3
Key Educational Points
  • Wood splinters are the most common foreign bodies in the hand.13,14
  • Ultrasound is the best imaging modality for identifying and localizing non-metalic foreign bodies.14
  • Foreign bodies in the hand or wrist are associated with risk for neurovascular, tendinous, capsular, ligamentous, and bony injury5
  • Treatment of foreign bodies remains a multifactorial and controversial challenge; clinicians must evaluate the mechanism of injury, character of wound, and risks of foreign body removal when making a treatment decision12
  • Hand and wrist foreign bodies should be removed immediately in the ED if it can be done readily and safely or when associated injuries necessitate a trip to the OR12
  • Healthcare professionals must carefully follow up with patients who retain a foreign body in the hand and monitor for any subsequent symptom presentation8
  • Failure to treat or diagnose retained foreign bodies in the hand is among the top 10 claims for most malpractice carriers, resulting in the fifth highest amount of indemnity awards to patients12
  • Radiology studies - X-ray:
    • Anteroposterior and lateral views are advised
    • Recommended for fragments of bone, some fish spines, glass, gravel/stone, metal/aluminum, pencil graphite, some plastic, teeth, and wood such as splinters, cactus spines, and thorns6
    • Not completely reliable for detecting glass and wooden foreign bodies2
  • Sonographic studies - Ultrasound
    • Recommended for fragments of glass, metal, pencil graphite, some plastic, stone, and wood6
    • Requires slow and meticulous scanning of the hand, which should be studied from multiple orientations to detect foreign bodies that do not lie parallel to the skin surface11
  • Radiology studies - Computerized tomography (CT) scanning
    • Should be reserved for cases of failed surgical explorations or infections
  • Magnetic resonance imaging - MRI without contrast
    • Can detect radiolucent foreign bodies and may be useful as a backup if other imaging studies fail to identify the fragment
References

Cited

  1. Anderson MA, Newmeyer WL, Kilgore ES. Diagnosis and treatment of retained foreign bodies in the hand. Am J Surg 1982;144(1):63-7. PMID: 7091533
  2. Saaiq M. Epidemiology and management of foreign bodies in the hand: pakistani perspective. World J Plast Surg 2014;3(1):13-7. PMID: 25489518
  3. Salati SA, Rather A. Missed foreign bodies in the hand: an experience from a center in Kashmir. Libyan J Med 2010;5. PMID: 21483579
  4. Mathur N, Sharma KK, Tiwari VK. An unusual foreign body in hand. A case report. J Hand Surg Br 1986;11(1):135-6. PMID: 3958537
  5. Hocaoğlu E, Kuvat SV, Özalp B, et al. Foreign body penetrations of hand and wrist: a retrospective study. Ulus Travma Acil Cerrahi Derg 2013;19(1):58-64. PMID: 23588982
  6. Halaas GW. Management of foreign bodies in the skin. Am Fam Physician 2007;76(5):683-8. PMID: 17894138
  7. Steele MT, Tran LV, Watson WA, Muelleman RL. Retained glass foreign bodies in wounds: predictive value of wound characteristics, patient perception, and wound exploration. Am J Emerg Med 1998;16(7):627-30. PMID: 9827733
  8. Smoot EC, Robson MC. Acute management of foreign body injuries of the hand. Ann Emerg Med 1983;12(7):434-7. PMID: 6349434
  9. DeBoard RH, Rondeau DF, Kang CS, et al. Principles of basic wound evaluation and management in the emergency department. Emerg Med Clin North Am 2007;25(1):23–39. PMID: 17400071
  10. Hollander JE, Singer AJ, Valentine S, Henry MC. Wound registry: development and validation. Ann Emerg Med 1995;25(5):675–85. PMID: 7741347
  11. Levine WN, Leslie BM. The use of ultrasonography to detect a radiolucent foreign body in the hand: a case report. J Hand Surg Am 1993;18(2):218-20. PMID: 8463582
  12. Potini VC, Francisco R, Shamian B, Tan V. Sequelae of foreign bodies in the wrist and hand. Hand (NY) 2013;8(1):77-81. PMID: 24426898
  13. Sherman CE, Murray PM.  Tumor-like conditions of the hand and upper extremity. J Hand Surg Am 2017; 42: 1009- 1017. PMID: 29089162
  14. Goldstein SA, Imbriglia JE. Erosions of the triquetrum and pisiform bones caused by foreign body. J Hand Surg Am 1986; 11(6): 899-901. PMID: 3794253
  15. Pappou IP, Deal DN. High-pressure injection injuries. J Hand Surg Am 2012; 37A: 2401-2407. PMID: 22999384

New Articles

  1. Saaiq M. Epidemiology and management of foreign bodies in the hand: pakistani perspective. World J Plast Surg 2014;3(1):13-7. PMID: 25489518
  2. Hocaoğlu E, Kuvat SV, Özalp B, et al. Foreign body penetrations of hand and wrist: a retrospective study. Ulus Travma Acil Cerrahi Derg 2013;19(1):58-64. PMID: 23588982

Reviews

  1. Halaas GW. Management of foreign bodies in the skin. Am Fam Physician 2007;76(5):683-8. PMID: 17894138
  2. Smoot EC, Robson MC. Acute management of foreign body injuries of the hand. Ann Emerg Med 1983;12(7):434-7. PMID: 6349434

Classics

  1. Anderson MA, Newmeyer WL, Kilgore ES. Diagnosis and treatment of retained foreign bodies in the hand. Am J Surg 1982;144(1):63-7. PMID: 7091533
Subscribe to FOREIGN BODY and FOREIGN BODY GRANULOMA
⇡