FOREIGN BODY and FOREIGN BODY GRANULOMA

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 examination^1,7
  • 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 marteial.  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

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.

• 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

• 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

• 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

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