East and Central African Journal of Surgery Association of Surgeons of East Africa and College of Surgeons of East Central and Southern Africa ISSN: 1024-297X EISSN: 2073-9990 Vol. 15, Num. 1, 2010, pp. 144-146

East and Central African Journal of Surgery, Vol. 15, No. 1, Mar-Apr, 2010, pp. 144-146

Case Report

Missed Foreign Body Presenting as a Chronically Painful Hand. A Case Report

S.A.  Salati¹, T. Rizvi ², S.M. Rabah¹

¹Department of Plastic &Reconstructive Surgery,
²Department of Radiology, King Fahad Medical City, Riyadh, Saudi Arabia
Correspondence to: Dr Sajad Ahmad Salati, Email: docsajad@yahoo.co.in

Code Number: js10025

Missed foreign bodies are common. They may remain asymptomatic or else lead to wide range of complications. We present an 8- years boy who suffered from chronic pain in his right hand case due to a missed foreign body.

Introduction

Foreign bodies might accidently penetrate the hand and might get missed when patient initially reports. Missed foreign bodies may become symptomatic after varied periods and lead to complications of bones and joints, soft tissue, nerves and blood vessels. The management comprises of accurate preoperative localization and surgical exploration and removal.

Case report

An 8-years old boy reported with about nine months history of getting pain in right hand on attempting to grip objects like handle of bicycle. There was no other significant past history. On examination, there was a 5 mm scar over the thenar eminence. The parents attributed this scar to injury, which was sustained while playing and managed by self-dressings. X-Rays of the right hand AP (Figure 1 and Figure 2) view showed a radiopaque foreign body on the volar aspect of proximal right hand in relation to carpal bones and carpometacarpal joint. No bony injury was seen.

The patient was operated upon under general anesthesia with proximal tourniquet haemostatic control and fluoroscopic guidance. Magnification was achieved with the help of magnifying loupes. A glass piece measuring 11mmx9mmx2mm was recovered (Figure 3). There were no perioperative complications and the patient was asymptomatic and pain free when reviewed three months follow-up.  

Discussion

Accidental penetration of the hand by foreign body is common, especially in children^{1, 2}. The patient may report at the time of injury when foreign body was detected on the basis of history, clinical examination³ and imaging^4.. The   foreign bodies may however be missed initially, particularly if these are not radio opaque such as thorns and wooden pieces⁵. A missed foreign body in fact forms a major cause of litigation against emergency physicians⁶. The patient may remain asymptomatic or with passage of time, develop wide range of complications including pain, abscess, chronic discharging wound, necrotizing fasciitis⁷,  bone and joint destructive lesions^1,8,migration^9,10, granulomas¹¹, delayed tendon ruptures^10,12, neurodeficits^9,13,14, and vascular events²  . 

Accurate preoperative localization is the key to successful surgical removal of foreign body as error at this stage can result in long intraoperative searches and extensive damage to soft tissues¹⁵. A foreign body may remain undetected even after thorough exploration⁵.

Conclusion 

• The possibility of presence of a foreign body should always be considered seriously at the time of initial management of wounds to prevent complications and future litigations.
• Presence of a foreign body should always be kept in mind as a differential diagnosis while evaluating cases of unexplained pain in hands and elsewhere.

References

1. N. Dastgir & P. O'Rourke : Pseudotumor Of Metatarsal: A Thorny Problem . The Internet Journal of Orthopedic Surgery. 2003 Volume 1 Number 2.
2. James W, Robert A, Suzanne M. Vascular Complications of a Foreign Body in the Hand of an Asymptomatic Patient  Ann Plast Surg1995; 34(1):92-94.
3. Lammers, R. L. Soft tissue foreign bodies. Ann. Emerg. Med.1988; 17: 1336-1347.
4. Ginsburg M.J, Ellis G., Horn L. L.: Detection of soft-tissue foreign bodies by plain radiography, xerography, computed tomography and ultrasonography. Ann. Emerg. Med. 1990; 19: 701-703.
5.  Anderson M. A., Newmeyer W. L., Kilgore E. S., Jr.: Diagnosis and treatment of retained foreign bodies in the hand. Am. J. Surg. 1982; 144:63-67.
6. Dunn, J. D.: Risk management in emergency medicine. Emerg. Med. Clin. North America.1987; 5: 51-69
7. Yanay O, Vaughan DJ, Brownstein D, et al. Retained wooden foreign body in a child’s thigh complicated by severe necrotizing fasciitis: a case report and discussion of imaging modalities for early diagnosis. Pediar. Emerg. Care 2001; 17 (5): 354-5.
8. Fakoor M Prolonged retention of an intra medullary wooden foreign body Pak J Med Sci 2006; 22 ( 1 ):78-79.
9. Choudhari K. A. ,  Muthu T.,  Tan M. H.    Progressive ulnar neuropathy caused by delayed migration of a foreign body Br J Neurosurg. 2001; 15( 3): 263 – 265.
10. Yang SS, Bear BJ, Weiland AJ. Rupture of the flexor pollicis longus tendon after 30 years due to migration of a retained foreign body. J Hand Surg [Br]. 1995; 20 (6): 803-5.
11. Freund EI, Weigl K. Foreign body granuloma. A cause of trigger thumb. J Hand Surg [Br]. 1984; 9 (2): 210.
12. Jablon M, Rabin SI. Late flexor pollicis longus tendon rupture due to retained glass fragments. J Hand Surg [Am]. 1988; 13 (5): 713-6.
13. Rainer C ,  Schoeller T, Wechselberger  G,et al Median nerve injury caused by missed foreign body Scand J Plast Reconstr Surg 2000; 34(4):401-03
14. González-García R, Rodríguez-Campo FJ, Román-Romero L et al. An interesting case: late sequelae of a primary asymptomatic glass fragment injury of the wrist.  Handchir Mikrochir Plast Chir. 1996; 28(6):306-8.
15. Coombs, C. J., Mutimer, K. L, Slattery, P. et, al. Hide and seek: pre-operative ultrasonic localization of non radio-opaque foreign bodies. Austr & New Zealand J. Surg. 1990; 60: 989-991

Copyright © 2010 - East and Central African Journal of Surgery

The following images related to this document are available:

Photo images