pdmr0398.htm

Foreign Body Removal

Author: Charles Stewart, MD, FACEP, Clinical Adjunct Associate Professor of Emergency Medicine, University of Rochester School of Medicine, Rochester, NY.

Peer Reviewer: Thomas Sherwin, MD, FAAP, Medicine Director, Pediatric Emergency Medicine; Associate Fellowship Director, Pediatric Emergency Medicine, Loma Linda University Medical Center, Loma Linda, CA.

Foreign bodies are a very common problem in the ED. Removing a foreign body from a child's hand, finger, or other area may be one of the most rewarding or frustrating experiences for both the patient and the physician.

Challenges to the emergency physician include identification of the presence of a foreign body. This may be difficult if there is no history on the child, or the clinical information is sketchy. In these situations, certain symptoms and types of injuries should heighten the physician's search for the possibility of a foreign body.

The second challenge, following identification of the foreign body, is removal of the object in the least painful manner possible. The author provides an excellent repertoire of available alternatives and ways to decide which method may be best in certain situations.

The third challenge is deciding when to involve a specialist, either on an emergent or elective basis. Certain foreign bodies may be left in position for a prolonged period of time, while others require immediate removal.

This article focuses on identifying and deciding on the removal method of the foreign body, enhancing the skills and alternative of the physician, and improving the comfort level of the patient during the challenging process of foreign body removal.

-The Editor

Introduction

Foreign body removal may be one of the most satisfying procedures that emergency physicians can perform. A young child, a parent (perhaps two), and the physician may all leave the ED with a feeling of accomplishment. Unfortunately, removal of a foreign body may also be a terrifying ordeal for the patient and a vexation and frustration for the physician. Unskilled attempts, numerous repetitions of painful techniques, extended searches, improper instrumentation, and inadequate lighting all contribute to dissatisfaction of both the patient and the physician alike.

It is usually not upsetting to most parents to be told that "We know your child has a foreign body and we can either leave it in place or remove it at leisure." It is particularly galling to be told that there isn't something there and later to find a foreign body at the site of an infection. It is so aggravating that failure to diagnose a foreign body in a wound has become has one of the most successful malpractice actions pursued against emergency physicians.1

How can we avoid this frustration for both physician and patient alike? As a reporter does with the news, a physician must answer several questions. How did this happen? What was inserted? Who did it? Where did it happen? When was it done? The physician must get some idea about what was inserted, when it was inserted, and how long ago it was inserted in order to plan how to best remove it. Wood or vegetable fibers should be removed as soon as possible. Metallic, glass, and plastic foreign bodies can be removed at leisure. Likewise, who inserted it may answer some intriguing questions. Remember that 3-5 year olds may share their "toys" with younger siblings and peers.

Nasal Foreign Bodies

A multitude of various objects have been found in a child's nose. Common objects inserted in the nose include beans, corn, beads, buttons, paper wads, marbles, crayons, peas, sponges, and small toys. Almost all nasal foreign bodies are smooth, since rough, irregular, and sharp objects are painful to insert. Objects such as beans, corn, peas, and paper swell when they are wetted by nasal secretions. This swelling may make removal more difficult. Button batteries may cause caustic local tissue damage.2,3In warmer climates, many insects and larvae will attempt to set up residence in the child's nose. Some of these animals can cause extensive tissue destruction.

Nasal foreign bodies in children frequently present as a unilateral rhinorrhea. Initially, the discharge may be thin, serous, and without smell, progressing to a foul-smelling mucopurulent discharge.4 Secondary infection may produce halitosis. Nasal foreign bodies are generally painless, so parents may detect no other signs or symptoms. If the history from the parents or child does not suggest the cause, looking in the nose often answers the question. Swelling and edema of the nose may be found. The swelling of the surrounding tissues may obstruct the nose or lead to sinusitis. If an insect is the foreign body, pain is more marked.

It is uncommon to see a child younger than 18 months with a foreign body inserted in the nose because they simply don't have the manual dexterity to put things there. Older children (up to 5 or 6) often don't divulge the presence of these objects immediately because they fear parental retribution. Multiple foreign bodies are quite common with children. (The author's record of removing these objects from one child is 4 foreign bodies in the nose and one in each ear).

The single biggest clue to diagnosis of a nasal foreign body is a unilateral nasal discharge or obstruction. Indeed, if this is found, the patient is considered to have a nasal foreign body until proven otherwise. The diagnosis is usually made by inspection of the nares. The most common location of the foreign body is adjacent to the inferior turbinate and below the middle turbinate. Examination of the posterior nasopharynx with a mirror may be appropriate, but is difficult in children. Radiographs of the nose are often recommended, but are more helpful in checking for a surrounding sinusitis. X-rays are of little value when radiolucent foreign bodies-such as crayons, paper, or food items-are noted and these are the most common items found.

A patient with a foreign body in the nose is at risk for aspiration of that foreign body, so the problem is not approached as casually as for a foreign body in the ear. The object must be removed. In truly uncooperative patients, endotracheal intubation and general anesthesia will ensure that aspiration does not occur.

Prior to removal of the foreign body, apply a topical decongestant nasal spray. This decreases the chances of blood obscuring the field and makes the removal much easier. Often the foreign body can be quite easily visualized after decongestant has been used.

The key to a successful removal on the first pass is reassurance and adequate immobilization of the child, good lighting, and use of appropriate instruments. A good headlamp is essential, and an operating microscope with integral illumination is very beneficial. A variety of sizes of nasal speculums should be readily available. (See Table 1.)

A small nasal speculum should be used to spread the nares in order to see the object. Slow and gentle motions, together with abundant "verbal" anesthesia are needed for the 18-month to 5-year age patient. If the foreign body is small, then small alligator forceps can remove it easily. A hemostat may be used to remove hard, rounded objects. A soft-tipped suction catheter can also be used for rounded foreign bodies. Suction may be needed to remove excessive mucous or pus and may easily remove food items.

Another successful technique includes passing a Fogarty catheter above the foreign body, inflating it, and tugging the foreign body out.5,6 A small Foley catheter (e.g., 8 French) could also be used for the same technique. It is very important to ensure that the catheter neither wedge the foreign body further into the nose nor push it into the nasopharynx. A small, right-angle blunt hook or a loop ear curette may be passed beyond the object and then turned to engage the object.7 A calcium alginate swab (Calgiswab) bent to a 90° angle near the tip can be used as a field expedient for a right-angle blunt hook.8 The author has used a loop ear curette bent to a 90° angle with good success.

For smaller children, parental positive pressure has been used quite successfully.9,10,11 Have the parent push gently on the opposite side of the nose to occlude the nares. Then have them puff gently into the patient's mouth. The positive pressure will make the foreign body pop out. This technique is often more difficult to explain than to do. Alternatively, an Ambu-bag or other positive pressure bag covering the mouth only may be used to express the foreign body.12,13

Table 1. Equipment Necessary to Remove Nasal Foreign Bodies

Topical anesthetic and decongestant of choice
Light source
Suction tip
Right-angled hook
Curved forceps
Bayonet forceps
Nasal speculum
Alligator forceps
Nasopharyngeal mirror
Ensure the discovery of (and do not be terribly surprised by) multiple foreign bodies. After the removal, bleeding (epistaxis) may occur. This can be treated in the usual manner. Residual inflammation of the nasal membranes will clear spontaneously over a few days. A follow-up visit in 2-3 days may be appropriate.

Complications. About the only significant complication is dislodging the object into the posterior pharynx and having the patient subsequently aspirate it. Trendelenburg position may decrease the chances of aspiration. Bronchoscopy will be required in these cases to remove the object. Swallowing the object is usually harmless (button batteries are an exception). Mucosal lacerations can occur when attempting removal in an unsedated thrashing or uncooperative child. Foreign bodies that are present for an extended time can erode into contiguous soft tissues; cause infections, including sinusitis and otitis media; and serve as a modus for formation of rhinoliths (nasal stones).14

If the foreign body can't be removed easily, then an otolaryngologist should be consulted. Multiple attempts to remove a foreign body may result in both a difficult patient and an exasperated parent. Beans, corn, and other vegetable matter may swell with the nasal fluids and become very difficult to remove, even with anesthesia and an operating microscope. Animate foreign bodies may require curettage under anesthesia.

Ear Foreign Bodies

Foreign bodies in the ear canal are also quite common, but auricular foreign bodies are an entirely different matter than intranasal objects. The exact incidence of auricular canal foreign bodies is not known. Children are often unable or unwilling to give any history at all. The event may be unnoticed, and the presentation may be a purulent discharge from the affected ear. If the patient has a perforated tympanic membrane (TM), then bleeding, hearing loss, vertigo, or discharge from the ear may be noted.
15The most common objects inserted in ears by children are pebbles, beans, beads, corn, small toys, and folded pieces of paper.16Button batteries are the right size for insertion and may cause caustic damage to both the canal and TM alike.17

Table 2. Removal of Ear Foreign Bodies

NECESSARY EQUIPMENT
Light source (at a minimum, an operating head otoscope)
Operating microscope if possible
Suction tips of various sizes-one with soft, flexible funnel tip if possible
Right-angled hook
Wire-loop ear curette
Curved forceps
Alligator forceps
Alternative bayonet forceps
Superglue
Microscope oil
COMPLICATIONS: 
Perforation of the tympanic membrane
Auditory canal lacerations
Ossicular bone damage
Further damage (iatrogenic)
 

The emergency physician with readily available resources and current techniques can probably remove more than 80% of foreign bodies.18 Methods that have been used successfully include forceps, irrigation, suction, ear curettes, right-angled hooks, Fogarty catheters, magnets, and superglue. The least-aggressive and invasive method should be attempted first.

The emergency physician should avoid aggressive or hurried attempts to remove foreign bodies. A methodical, unhurried, and planned approach is essential to retain the child's cooperation. Emergency removal of foreign bodies in uncooperative children is necessary only for signs of obvious infection, disc batteries, and insects. An operating microscope and optimal sedation may be needed for some foreign bodies. Permanent damage to the ossicles or TM can result from pushing the object further into the canal. Multiple attempts at removal are inappropriate, and emergency physicians should be willing to acknowledge defeat to both him or herself and parents alike.

If the foreign body can't be easily removed, then an otolaryngologist should be consulted. Multiple attempts to remove a foreign body from the ear may result in trauma to the ear and to the patient. Remember that the first attempt at removal will be the very best shot, after this, everything is downhill.

The size, shape, and material of the foreign body have a large influence on the method of removal of the foreign body. Most foreign bodies will be located at the juncture of the bony and the cartilaginous auricular canal. This means that the object will be in the outer two-thirds of the canal and away from the tympanic membrane. Smaller objects and insects may be directly against the sensitive TM.

Attempt removal only under good lighting with direct visualization of the object. An operating microscope is ideal, and an operating head on an otoscope is the minimal resource. Operating auricular speculums in various sizes and a headlamp are an appropriate compromise between cost and effectiveness. (See Table 2.)

If at all possible, grossly assess the hearing both before and after removal of the object . Always ensure that there is only one foreign body.

Caution the patient or parents to avoid water both before and after removal of the foreign body. This is particularly important with vegetable materials such as beans, peas, and corn. Since the ear is fairly dry, sprouting and swelling is not usually a problem with vegetable foreign bodies. Wetting these can cause them to swell or sprout and markedly increase the potential damage.

The patient's head should be stabilized during the procedure to prevent inadvertent movement while the examiner has an instrument near the tympanic membrane. An assistant or nurse should stabilize the patient's head-not the parent. Hold the instruments loosely between thumb and forefinger while the tools are within the ear canal. If the patient does move, the loose grip will allow the instrument to move with the motion of the patient. Rigid instruments should be used with great caution in uncooperative patients. If the patient moves suddenly, the instrument can seriously damage the middle ear structures.19

Warn the parents that it is quite possible to scratch the lining of the external canal and that the resultant bleeding does not reflect damage to the structures of the ear. This explanation is often better received before the removal attempt than when blood wells up after a successful removal.

The cutaneous lining of the ear canal is quite sensitive and not much affected by topical anesthetics. Although multiple texts will describe anesthesia techniques to remove foreign bodies in the ear, these techniques are so painful as to almost be defined as cruel and unusual punishment. There is little to be gained from this anesthesia over standard methods of conscious sedation, if such is required.

Foreign Bodies. Small objects may be easily removed with forceps. Large objects should not be removed with forceps. As the forceps are advanced, the conical bony ear canal will cause them to close. Unless there is a protrusion on the object, this closure will likely push the object further into the bony canal. Beads with a hole may be grasped by putting an alligator forceps into the hole of the bead and spreading the end. Irrigation may be suitable for multiple small bodies, but the examiner must be certain that there is no perforation of the tympanic membrane.

Smooth, rounded objects can sometimes be removed with suction. The Richards Manufacturing Company makes a small plastic suction catheter with a soft funnel shaped tip. This greatly aids removal of the object. Small children may balk at the loud noise that this device makes, but it is easy to demonstrate that no harm will ensue. Inserting a tympanostomy tube in the tip of a No. 7 Frazier suction tube can make a similar device. 20

A thin right-angle hook may be introduced gently and slowly around the object. The hook is rotated behind the foreign body and traction applied. In a similar technique, the physician may slide a Fogarty catheter behind the object, inflate the balloon, and use the catheter for traction on the object. Due to the very small space within the ear canal, this may be dangerous to the TM and quite painful if the balloon is overinflated.

Another technique that has not been extensively studied but shows promise, is to affix the object with superglue.21,22 A small drop of cyanoacrylate (superglue) cement is placed on the blunt end of a cotton swab. The stick is carefully introduced into the ear canal. No contact with the ear canal should be made. The stick is touched to the object and held in place for a minute. When the stick is removed, the object should be attached.

Do not attempt removal of an impacted smooth foreign body in an uncooperative child. Foreign bodies that are round and fit snugly into the canal can be quite difficult to remove under the best of circumstances, with the best tools, in a completely cooperative patient. The emergency physician will not help a fighting 2-year-old child by attempting to dig out a bead with inadequate tools under suboptimal lighting. Simply inform the parents that this object will best be removed under anesthesia by an otolaryngologist. Don't make parents feel guilty because the child is too young to remain still.

Insects. Insects are an interesting challenge. The movement, buzzing of the wings, and occasional stinging or biting make these foreign bodies exceptionally irritating. Patients will often arrive panic-stricken to the ED. Immobilization of the insect is advocated to decrease these motions and to facilitate removal of the insect. Insects may be effectively immobilized with mineral oil, acetone, alcohol, or Xylocaine.23,24 Of these agents, the largest controlled study showed that mineral oil immobilized the insect the fastest. Highly refined mineral oil is readily available in most hospitals as microscope immersion oil. Insects may fragment during removal and irrigation may be the quickest way to get them out.

For parents who call and ask advice about this problem, baby oil and vegetable oil would be readily available in many households. These are functionally equivalent to mineral oil and could kill the insect en route to the ED. This would markedly decrease the patient's suffering and expedite removal in the ED.

Soft-Tissue Foreign Bodies

Location Techniques.Establishing the diagnosis of a soft-tissue foreign body may be quite simple or exceptionally difficult. The mechanism of injury provides the first clue that a foreign body is involved in the wound. If a history of injury is not present, diagnosis will be delayed. Even small, seemingly superficial wounds should be investigated for foreign bodies. As one author notes: "No wound is too small to harbor a foreign body."25

A careful visual inspection of all puncture wounds is appropriate. This should be performed under good lighting with careful exposure of the wound. Local anesthesia and an ischemic tourniquet may be appropriate in some situations. The physician may palpate a superficial foreign body in the wound with either a gloved finger or an instrument. Useful signs that a foreign body is in the wound include sharp pain with palpation over the wound, pain on movement, or a mass in the wound.

It is important to remember that if a wound heals poorly or is particularly painful; it should also be investigated for a foreign body.26 Antibiotics may temporarily improve an infection but it will recur if the foreign body remains. Any wound infection that gets better with antibiotics only to return when the antibiotics are stopped should be considered to have a foreign body until proven otherwise.

Complications of a retained foreign body include pain, infections, peripheral nerve damage, vascular damage, and synovitis.27-31 Of these, pain and infection are the most common complications. Foreign body reactions are quite common and may be caused by wooden splinters, nylon fibers, cactus bristles, plastics, and many other materials.

Radiographic Techniques. All methods for detecting a superficial foreign body have limitations. However, radiographs can easily localize, discover, and guide the removal of radiopaque objects. A needle or paper clip can be used to localize the wound entrance prior to getting the radiograph.32 Needles at right angles can create a reference plane to localize the foreign body.

One common misconception is that glass must have lead present in order to be visible on an x-ray. Glass was first shown to be visible on x-ray in 1932 by Lewis.33 Numerous subsequent studies have completely confirmed this for all types of glass in pieces as small as 0.5 mm.34-36 Glass is visible regardless of pigment content or source. Because almost all fragments of glass are visible on x-ray, an x-ray should be obtained whenever there is any suspicion of imbedded glass fragments.

Standard x-rays, computerized tomography, and xeroradiography are not particularly useful if the foreign body is not radiopaque. If the foreign body was recently introduced, then there may be some gas introduced within the wound. This may suggest a foreign body but cannot conclusively identify one.

Wood, in particular, is not easy to see on standard radiographs. Painted wood may occasionally be identified by the pigments in the paint. Thin sections with multiplane reformatting may enhance wood visibility on CT scan.37 Cloth, plastic, foam from tennis shoes, spines, and cactus thorns are also difficult to see on an x-ray. These radiolucent foreign bodies may be suspected by deep soft-tissue thickening, swelling, or bony changes seen on the radiograph. Soft-tissue gas that accompanies the foreign body may outline wood fragments, thorns, and spines.

The identification of these materials may be enhanced by use of techniques such as ultrasonography, xeroradiographs, and magnetic resonance imaging.38,39 Of these, ultrasound combines both reliability and lower cost. If a superficial foreign body is suspected but not detected on conventional radiographs, the use of ultrasound should be considered.40-42

Xeroradiographs can be used to search for foreign bodies because the Xerox process enhances the contrast between the foreign body and the surrounding tissue (edge enhancement). Wood, plastic, rubber, and graphite are more easily seen with the xerogradiogram than by plain films.

A CT scan is quite useful for locating objects and approximating size. A three-dimensional picture that shows the location may be generated and used to accurate location of the foreign body. Unfortunately, CT scanning is also costly and delivers a high radiation dose to the tissues.

Removing Cutaneous Foreign Bodies. General principles. There are several basic requirements for successful removal of a soft-tissue foreign body. Lighting, adequate instruments, and appropriate anesthesia will all aid in visualization. Appropriate hemostasis, either by the use of a tourniquet or local vasoconstrictor, will help greatly in the search. Before the wound is anesthetized or opened, the neurovascular status of the patient should be noted and documented.

The physician should set a time limit on searches so that both the patient and the physician will not tire over time. About 20-30 minutes is appropriate and should suffice for an adequate exploration. After that time, further searching is not likely to be successful and often increases the likelihood of tissue damage.

If the child is at an age where cooperation is impossible or unlikely, or an older child is unable to tolerate the procedure, then conscious sedation or general anesthesia is indicated. Even if the removal must be deferred, this is preferable than attempting removal of a foreign body in a thrashing patient.

A standard suture kit with a scalpel is normally enough equipment to remove most foreign bodies in most locations. Tissue retractors and Metzenbaum scissors may be useful additions to this equipment.

In general, the foreign body should be removed under direct visualization. Never blindly grab something in a wound with a hemostat. Vital structures may be badly damaged by this technique.

The wound should be explored with Metzenbaum scissors or a hemostat-by-spreading technique. The hemostat or scissors are introduced into the incision, spread to open the tissues, and used to feel for the foreign body as they are advanced. Scissors may be used to widen the incision to better see and remove the object. Incisions should usually be made transverse to the suspected foreign body rather than in line with the foreign body.

If a foreign body is difficult to see, grasp, or if the material stains the surrounding tissue, then en block dissection may be appropriate. In some cases, a deep elliptical incision around the wound entrance can remove both the foreign body and contaminated tissue. This technique must avoid vital structures. It is quite suitable for highly contaminated and vegetable foreign bodies.

Following removal of the foreign body, the area should be thoroughly cleansed. High-volume and low-pressure irrigation are best to clean these wounds. Significantly contaminated wounds may be managed with delayed primary closure.

Fishhooks

Fishhook injuries are common in both sport and commercial fishing. Fishhooks come in many different sizes and two types: one type is barbed along the shaft, and the other type has no barbs on the shaft. Treble hooks have three sets of barbs and hooks on the same shank, while double hooks have two. Many lures have one or two treble hooks attached. Large fishhooks can do substantial damage when entangled.

There are many methods for removing fishhooks, which means that there is no one perfect method yet. The following methods have all been tried by the author with varying degrees of success. If the hook is in or near the eye, then an ophthalmology consult should be obtained.

Precautions. Ensure that the other barbs in multiple-barbed lures are either protected with tape or removed before starting any of these techniques. It is embarrassing to remove a fishhook only to have another hook on the lure imbed in another part of the patient, a parent, or the physician. If the fisherman is worried about an expensive lure, remind him that the lure can be repaired at a good sporting goods store.

Table 3. Equipment Necessary to Remove Fishhooks

Gloves
Hemostat
Wire cutters
Scalpel with # 11 blade
18 gauge needle
Skin prep materials
Dressing materials
Anesthesia equipment:
25 gauge needle
5 cc syringe
Local anesthetic of choice
 
General Techniques.Clean the area surrounding the puncture wound with Betadine. Don't soak the area. It adds nothing to the cleanliness of the area and may be quite uncomfortable when there is a lure attached to the hook.

Local anesthesia is generally needed to aid the removal of a fishhook. (See Table 3.) The site of entry should be anesthetized with a small wheal of local anesthetic. For fingers, a digital block may be more appropriate.

Once the hook has been removed, the area should be recleaned and a topical antibiotic applied. Bacitracin or other topical antibiotic generally will suffice. Systemic antibiotics are not needed unless the hook has impaled tendon or cartilage. If the wound is particularly large, antibiotics may also be indicated. Tetanus status should be evaluated and a booster given if appropriate. Advise the patient about the risk of infection and give appropriate instructions about wound care. Instruct the patient to return if signs of infection develop.

String-Pull Technique. The string-pull technique has been well described in the literature.44-47 It is fast and relatively painless with a high rate of success.48,49 Theoretically, no anesthesia is needed.

First, tie a string about 2 feet long to the hook at the curve of the hook. Push the hook shank down (towards the barb) parallel to the skin. This should disengage the barb from the tissue. Hold the other end of the string and pull the string away and with a 30° angle to the skin. If the wrist is snapped away from the embedded site, the hook will also be snapped out.

The major disadvantage to this technique is the potential for a flying foreign body that can be impaled in the examiner, witnesses, or the patient. If the examiner has any pause or hesitation in the removal process, then this technique can inflict considerable pain. The author has had limited success with this technique in removal of fishhooks from children.

Advance-and-Cut Technique. The oldest technique described in the literature is to advance the barb through the skin and then cut the barb off. It is probably best reserved for cases where the barb is already visible through the skin or when another technique has failed.50 If the patient has an imbedded barbed shank fishhook, this technique may also be the most appropriate.

Grasp the fishhook with a needle holder or pliers and push it through the skin. Cut the fishhook behind the barb and remove the rest of the hook back out the entrance wound in a retrograde fashion. Needless to say, local anesthesia is recommended for this procedure.

Needle Cover Technique. In the needle cover technique, the practitioner should insert an 18 gauge needle along the tract of the entry wound. The needle should be placed to sheathe the barb of the hook so that it doesn't catch on tissue. Small strands of tissue may be incised with the sharp edge of the needle. With the barb covered by the needle, back the needle and hook out as one unit.

This method is relatively painless even without anesthesia and has a high rate of success. The author prefers this technique since there is no potential for flying objects and little secondary damage results. It does require a bit more coordination than the other techniques, and may not be as useful for very large fishhooks.

Simple Retrograde Technique. Some authors describe the string technique without the string, calling it the streamside technique or simple retrograde technique.51 Use the index finger to depress the tip of the hook and disengage the barb. The fishhook is removed by using gentle pressure on the shank of the fishhook while backing out the hook. This technique is only useful if the fishhook is superficial and the barb is not caught on fibers in the skin.

Cut It Out. If all of the other techniques fail or are inappropriate because they may endanger vital structures, the hook may be surgically removed with direct visualization of the wound. Direct exposure does allow for a complete irrigation of the wound tract. This may be important in some patients to lessen the possibility of infection.

Use a scalpel to extend a small incision from the entrance wound to the barb. Use scissors to bluntly spread and dissect tissue until the barb is directly visible. Grasp the tip of the hook with a hemostat and lift it out. Thoroughly irrigate the wound after removal of the object.

Splinters

Simply pulling the end of a superficial protruding splinter may leave small shreds of wood. This technique is often tried prior to arrival in the ED. Wood is very reactive and will cause inflammation if left in place, so even small pieces of wood must be completely removed from soft tissue. Some woods, such as redwood and cedar fragment quite easily. Wood that fragments will require extra effort to ensure that no small pieces are left behind.

If the wood is palpable beneath the skin, it may be more appropriate to make an incision along the axis of the splinter rather than to try to drag the splinter out through the entrance wound. After removal of the splinter, the tract can be thoroughly cleaned and any small remaining pieces extracted.

Nailbed Splinters. Splinters that are beneath a nail pose additional problems. If they are not completely removed, then an infection is quite likely. In some cases, this may mean that a small wedge-shaped segment is removed from the nail and the underlying splinter curetted out. This small segment may be removed by shaving the nail with a scalpel blade until the splinter is found. This procedure is virtually painless when properly done, until the nail bed is encountered. Alternatively, sharp scissors may be used to excise the portion of nail. When these procedures are used, a digital block of the finger may be quite helpful.

Catfish Spines

Fish stings in fresh water are most often caused by catfish. The incidence is unknown, and most stings are probably not reported. Because catfish stings occur when the animal is handled or excited, they often involve the hands and arms.52

The venom apparatus is located in the anterior portion of the dorsal fin and the two pectoral fins, on a single spine in each location.53 These spines are sharp, may have retroserrated teeth, and are fixed in the extended position when the fins are erected. Like the stingray's sting, these spines are enveloped with a sheath that encloses glandular toxin-producing tissues.

As the sting enters the skin, the enveloping sheath is ruptured. The venom-producing tissue is exposed and releases venom into the wound. The marine catfish is thought to have a more serious sting than the freshwater catfish, but this may be merely a factor of size.

The effects of catfish stings are comparable to a mild stingray envenomation. Variously described as stinging, burning, or throbbing, the pain is out of proportion to the small puncture wound usually found. The pain peaks in about 30 minutes, and small species may cause effects lasting only 2-3 hours. The wound generally has an ischemic, dusky margin that gradually resolves and progresses to a hyperemic reactive area around the site of the sting. Those species with recurved teeth may inflict significant lacerations.

Systemic effects include nausea, muscle spasm, sweating, and muscle fasciculations. Radicular pain in the affected limb is not uncommon. Rarely, and generally only with saltwater catfish stings, syncope, hypotension, respiratory distress, and death have been noted.54,54

Secondary infections are common and lymphedema, lymphadenopathy, and lymphangitis may all be found. Localized necrosis due to infection may be seen in inadequately treated stings.

Hot water will inactivate the heat-labile toxin( maximum, 45°C [113°F]) and will afford significant pain relief. Local infiltration of lidocaine without epinephrine may also provide pain relief.

Radiographic identification and surgical exploration may be needed for spine and investing sheath fragments. Primary closure of the wound is not recommended. Delayed primary closure may afford the best cosmetic and surgical results.

If adults handle fish caught by children, then this injury will be unlikely in younger patients.

Cactus Spines

Myriad visits for abrasions, scratches, and puncture wounds caused by plants are poorly documented and completely untallied. The perils of roses, brambles, briars, and cacti are well known and documented in folk literature. These thorns and spines vary considerably in size and the difficulty in removal is probably inversely proportional to the size of the object.

The most well-recorded injury recorded in the literature is the trauma resulting from the spines of cacti.56 These plants are ubiquitous in the Southwest, as many a child has found during a fall. Cacti are also found as ornamental plants throughout cities, gardens, and houses. The typical patient will give a history of a fall from a ledge, horse, cross-country motorcycle, or all-terrain vehicle. Many younger children will be brought to the ED shortly after the fall, literally bristling with spines. Older children may delay several days and present with multiple grouped pustular lesions, typically on the buttocks or lower extremities. Penetrations of thorns, spines, and cacti can lead later to an imbedded foreign body with subsequent foreign body granuloma.57 These plant-induced granulomas must be differentiated from other causes of granulomatous disease by biopsy.

Usually, spines can be easily, but tediously, removed with forceps. Some physicians feel that these spines will be easier to remove a few days after the initial trauma, when a local reaction is present and the spines are more readily identified. For spines that are too fine to remove with forceps or splinter tweezers, apply rubber cement to the area.58 Then immediately apply paper to the rubber cement. When the cement has hardened, the paper can be peeled off together with the spines. Alternatives that have been used include depilatory wax, commercial facial gels, and household glue.59-62 Facial gels may require multiple applications in order to remove the spines.

Steroids will provide little relief for the foreign body reaction, as long as the foreign body remains imbedded. Antibiotics should be reserved for areas of obvious infection.63

Rings

Injuries to the arm, hand, or the finger may cause swelling of fingers with rings on them. These injuries can include burns, lacerations, crush injuries, fractures, and bites. Children may attempt to insert fingers in colorful objects. If the patient has an injury to the hand or arm, swelling of the finger should be anticipated and rings removed early in the patient's course. Rings that are somewhat tight may occlude venous flow and cause swelling, making the ring tighter and so on in a vicious cycle of swelling. Once swelling has fully developed, the procedure may be quite difficult.

Remember that "rings" are not always jewelry, and jewelry is not always gold, silver, or platinum. Children may try on pretty objects that look like rings, only to have difficulty removing them. "Pop-tops" in particular have been used by children as jewelry. Some subcultures may use stainless steel for decoration, including rings. Ceramic-backed rings may be quite challenging to remove. (See Table 4.)

First, lubricate the area with KY jelly, and then try to remove the ring with a circular motion and traction on the ring. Elevation and cooling the involved digit for 10-15 minutes with either ice or very cold water may be of some help. If these simple techniques don't work, then it is time to try the string wrap method or to cut the ring off.

Wrapping Technique. About 15-20 inches of stout string, thin umbilical tape, or a thick silk suture is passed under the ring. A hemostat may be passed under the ring from the proximal side to grasp the wrapping.

The finger is then wrapped in spiral fashion from just proximal to the ring all the way past the distal interphalangeal joint. The wrap must be closely approximated so that no tissue bulges and the tissue is completely compressed beneath the wrap. The string is unwrapped by pulling on the proximal end and forcing the ring towards the end of the finger. (See Figure 1.)

This procedure may be painful and require a digital block. If there are injuries distal to the ring, the string technique is not appropriate. The author has had varying success with this technique. It appears to work best on younger patients where the size of the joint is close to the size of the digit. If the wrapping technique fails, don't continue to fruitlessly wrap and rewrap the finger.

Don't try to save a ring only to lose the digit. If the digit is ischemic, simply cut the ring off.

Table 4. Equipment Necessary to Remove Rings

Ring cutter, power cutting tool (Dremel or Craftsman), or hacksaw for metal objects
Commercial bolt or wire cutter for thin metal objects
Padding, protection, and colling if hacksaw or power tool is used
WRAPPING TECHNIQUE
String, umbilical tape, or stout silk suture
KY jelly
Digital block equipment
RING CUTTER TECHNIQUE
Ring cutter
Needle nose pliers or needle holders (2)
Steel and other hard rings
GLASS OR CERAMIC RINGS
Diamond glass scoring tool for glass objects

Ring Cutter Technique. The quickest method of ring removal is to "simply" cut it off. For aluminum, pewter, and precious metal rings, this is quite simple. It becomes more difficult with copper, brass, or soft steel rings and may be very difficult indeed with hardened steel washers used as rings. A standard ring cutter has a small hook that fits under the ring. This hook serves as a guide and tissue protector for a manual powered saw wheel that cuts the metal. Select the thinnest site on the ring to cut (usually opposite stones or settings). Rotate this side away from any injury if possible or on the palmar surface of the ring. Spread the ring only enough to remove it without further trauma to the finger. A precious metal ring can be repaired if it is cut and removed in this manner.

Standard ring-cutter saws are designed for use on precious metals and will simply not cut hard metals well. Indeed, for some high tensile-strength steel washers, only a diamond-backed hacksaw blade or a power tool will suffice. The author has used a Dremel Moto-tool operated at low speeds with a diamond-backed dental cutting tool. The noise of powered cutting tools may be quite distressing to children. If the metal requires a hacksaw blade or power tool, be certain that the digit is padded and protected from slippage and from heat generated by friction. Allow plenty of time for cooling the object between cutting passes. Water cooling may be required in some cases to prevent burns. Although most textbooks will describe making only one cut, if a ring or washer of these harder metals is encountered, two cuts 180° apart are much more appropriate. Attempting to bend a high tensile strength washer or ring with a hemostat is a certain way to damage the hemostat and possibly both patient and physician alike. (See Figure 2.)

Glass or ceramic rings. Ring cutters are also not effective for glass objects. Glass rings (and soda bottles) can be scored with a diamond cutter on two sides. A sharp rap with a small hammer will fracture the ring at the site of the score marks. Since the force vectors of this maneuver are away from the finger, no damage should result to the finger.

Zippers

The child's thin foreskin, abdominal skin, or vulva (rarely), may occasionally be caught in the mechanism of a zipper. This is exquisitely painful. If the zipper is unzipped, more tissue may be caught in the mechanism and the skin may be lacerated.

Zippers are most easily removed by cutting the zipper "diamond" or median bar that holds the slider together with a bone cutter or a pair of wire clippers. When this is done, the zipper will fall apart. (See Table 5.)

Table 5. Equipment Necessary to Remove Skin from Zippers

Commercial bolt or wire cutter
Dental wire cutter may be destroyed by this technique

Penile Foreign Bodies

Children may present with hair, rubber bands, or thread wrapped about the penis causing a tourniquet-like effect.65,66This entity was first described by Guillimeau in 1612.67The loop of hair may be nearly invisible in the edematous tissues. It may be easily severed after anesthesia and exposure.68This trauma may also be associated with sexual abuse of the child.
69

In adolescents, rings on the penis may occasionally be used to enhance both the duration and size of an erection.70 These rings can also cause swelling and necrosis distal to the ring. These penile rings, called "cock" rings, may be made of leather, plastic, or steel. Penile rings should be removed with the same technique as described above for rings on digits. The author has found that the string wrapping technique is a waste of time for rings on this organ. Plastic and leather rings may be removed with a ring-cutter. If a metal "cock" ring is encountered, always use two cuts to remove it so that there will be less trauma to the penis.

Ticks

A variety of various plants, substances, stratagems, and tools have been devised to aid in removing a tick. With millions of years of evolution in learning how to stay attached to moving animals, it is not surprising that the tick frequently remains attached despite our wishes.

The mouth parts consist of two retractile jaws, a pair of short appendages (palps), and a central probe with recurved teeth (the hypostome). These structures are attached to a plate called the capitulum.71 The tick attaches to the host with its mouth parts, which not only are imbedded in the skin but are also glued into place with a cement-like secretion. The tick can voluntarily detach from its host but, when forced off, may leave the capitulum and attached mouth parts imbedded in the skin. As long as the mouth parts are attached to the patient, the patient remains at risk for tick paralysis and tick fever.

There is no completely effective method for removal of ticks. One author evaluated five popular methods of removing ticks and felt that the tick would best be removed by grasping the tick close to the skin and exerting a steady even pressure.72 Grasping the body of the tick with fingers, forceps, or tongs, and then pulling it off may leave the mouth parts behind. Likewise, twisting or jerking the tick may cause the mouth parts to break off. When the tick is grasped, the squeeze may inject additional saliva and more microorganisms through the mouth parts. Crushing or puncturing the body of the tick may release additional infective agents with the tick's body fluids. One author freezes the tick with ethyl chloride and then removes it with forceps to decrease the risk of injection.73

Common folk remedies include application heat or organic solvents to the tick's body. Application of a heated match, cigarette, or cautery to the tick body will occasionally cause the tick to back out of the skin, but is more likely to cause burns to the victim. It is unlikely, indeed, that a child will tolerate this procedure. A very likely outcome is the death of the tick, prior to disengagement. Application of an organic solvent, such as chloroform, ether, gasoline, or fingernail polish, may also cause the tick to disengage itself but is more likely to result in the death of the tick. Needless to say, do not use a cautery or flame after application of such substances.

Finally, dead ticks (most often seen after one of the above methods has been tried and failed) should be removed by surgical excision of a small portion of the skin in order not to leave any mouth parts remaining. This can be done with an 18 gauge needle used as a scalpel.

Precautions. While removing the tick, gloves should be worn because any minor abrasions may permit infection of the operator. Fingers should not be used to handle the tick or squeeze the tick, since tick feces and body fluids can also be contaminated. These precautions are particularly important for those who are "deticking" animals with multiple ticks.

Table 6. Equipment Necessary to Remove Foreign Objects from the Penis

Fine scissors for hair, rubber bands, and string
Ring cutter or hacksaw for metal objects (padding, protection, and cooling if hacksaw is used)
Diamond glass scoring tool for glass objects
 

Summary

Foreign body removal may be one of the most satisfying procedures for the patient, the family, and the ED physician. Resources, special techiques, and confidence in one's skill can enhance the ability of the physician to perform these procedures with minimal complications and frustration. In some cases, extreme caution is necessary in removing the foreign bod; in most cases, however, common foreign bodies can be identified and removed with ease and without the need for specialist referral.

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