foreign bodies in soft tissue / skin

introduction

failure to diagnose retained FB's in wounds are a common cause of medico legal issues
where open wound or puncture injuries are sustained with objects such as broken glass, efforts should be made to detect retained FB such as plain XR (although most glass does not show on Xrays), or better still, soft tissue ultrasound scan
retained FB's substantially increase the risk of infection and tetanus
nail gun injuries are very common and can be associated with:
- retained glue
- fractures / compound injuries
- structural damage
- deep seated infections

attempting to remove a FB which is not visible or palpable in the ED without US or flouroscopic guidance and a relatively bloodless field is likely to be extremely time consuming, often futile, and risks unnecessary damage.

historically, large protruding objects have been advised to be left in situ until patient is in theatre in case their removal causes exsanguination.
current views are generally that most can be removed as the probability that the object is indeed tamponading or compressing a lacerated blood vessel is very low
however, it generally makes sense to:
- first image the injury to document the path the object has taken, and evidence of underlying structural damage such as bone fractures
- discuss with surgical team as to whether they are happy the object is removed

consider XR to locate FB, exclude other FB's and bony injury
consider USS to determine if FB is present and to assist in locating its exact position
tetanus prophylaxis as needed
removal in ED can be attempted if:
- FB is visible or palpable, or has been located and identified with a needle using US guidance, AND,
- adequate analgesia or anaesthesia is possible, AND,
- one is confident that no important structures such as nerves, arteries, tendons or joint capsules will be damaged, AND,
- patient does not need exploration in theatre (eg. compound fractures, contaminated wounds), AND,
- ED resources allow one to spend an hour attempting to remove it, AND,
- injury is recent within past day or so, AND,
- location and complete extraction is expected to be feasible in ED +/- relatively bloodless field
otherwise most cases should be referred to plastics

local anaesthesia
identify location of FB using US and 25G needle tip at FB site
if unlikely to be extracted by pulling from entry or exit wound, incise skin over length of FB as long as vital structures will not be damaged