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1277
Localization and Guided Removal of Soft-Tissue Foreign Bodies with Sonography
William E. Shiels 1113 Diane S. Babcock1 James L. Wilson2 Reed A. Burch2
Sonography was used to detect, localize, and guide removal of foreign bodies in the soft tissues of the extremities and neck. Twenty localization procedures were performed in 19 patients (12 children and seven adults) with 21 foreign bodies including wood, glass, stone, metal, and lead pencil. Localization was accomplished by using anatomic landmarks, ink marks on the skin, and needle and hemostat markers. Localization was facilitated by the use of small standoff pads that were cut for use on small surfaces. The foreign bodies were visualized as hyperechoic foci with acoustic shadows that were partial or complete depending on the angle of insonation and foreign body composition. Hyperechoic comet-tail artifacts (reverberation artifacts) were seen with six metallic foreign bodies and one glass fragment. Nine foreign bodies were surrounded by hypoechoic halos caused by edema, abscess, or granulation tissue. A slow meticubus scanning technique and high-frequency transducer helped in detection of small foreign bodies. Sonographically guided removal of the foreign body was successful in all four patients in whom it was attempted. Scanning with the ultrasound beam parallel to the long axis of the hemostat and the foreign body was the fastest way to guide the hemostat to the tip of a foreign body. The procedure was accomplished most easily and quickly when one physician performed sonography and hemostat removal of the foreign body simultaneously. Our experience with these cases indicates that sonography is a useful tool in the localization and removal of soft-tissue foreign bodies. AJR
Received February 27, 1990; accepted vision June 29, 1990.
after re-
The opinions or assertions contained herein are the private views of the authors and are not to be construed as official or as reflecting the views of the Department of the Army or the Department of
Defense. Presented at the annual meeting of the Society for Pediatric Radiology, San Antonio, TX, April 1989. 1 Department of Radiology, Children’s Hospital Center, and the Departments of Radiology and Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH 45229-2899. 2 Tripler Army Medical Center, Honolulu, HI
155:1277-1281,
December
1990
Soft-tissue foreign bodies are a common clinical problem in both children and adults. Traditionally, radiographs have been used to identify radiopaque foreign bodies and fluoroscopy has been used for guidance during surgical removal. Recent reports have demonstrated the usefulness of sonography in the detection, preoperative localization, and confirmation of surgical retrieval of foreign bodies in the distal extremities [1-4]. We report a series of patients in whom sonography was successfully used for detection, localization, and removal of soft-tissue foreign bodies in the extremities and the neck.
Materials
and
Methods
Medical
96859-5000. Present address: Department of Radiology, Walter Reed Army Medical Center, Washington, DC 20307-5001. Address reprint requests toW. E. 3
Shiels II. 0361 -803X/90/i
556-1 277
Twenty-six patients were referred for sonography because bodies in soft-tissue between March 1 986 and May 1 990. surgeons
either
before,
during,
or
after
exploration
for
of possible retention of foreign The patients were referred by
possible
soft-tissue
foreign
bodies.
The 1 9 males and seven females were 1 -37 years old (mean, 13 years). Nineteen patients were between 1 and 17 years old, and seven were between 22 and 37 years In 24 patients, plain radiographs were obtained before sonography. In two patients, with a known wooden splinter in the thigh and one with a lead pencil fragment in the no radiographs were obtained. Surgical removal had been attempted unsuccessfully patients.
of the
old. one hand, in five
SHIELS
ET AL.
with Acuson 1 28 (Mountain View, CA); 4, or ATL-Mark 300 (Bothell, WA); and (Cleveland, OH) systems, using 5.0-, 7.5-, and 10.0Commercially available standoff pads (Kitecko, 3M,
Results
1278
Sonograms ATL-Ultramark Picker
were obtained 8, ATL-Mark
Microview
MHz transducers. Roseville,
MN,
and
Aquaflex,
Parker
Laboratories,
Inc.,
Orange,
NJ)
Downloaded from www.ajronline.org by 157.89.65.129 on 11/24/14 from IP address 157.89.65.129. Copyright ARRS. For personal use only; all rights reserved
were used to provide
adequate visualization of the skin and superficial Preoperative localization was performed by marking the
soft tissues. skin
with
with
permanent
ink markers.
skin-marker positioning metal beads attached Beekley Corp., Bristol, four
intraoperative
parison
images
Imaging tients.
Needle
localization
was
performed
1 9- or 27-gauge
either
sonographically
of the opposite
guidance
Four
needles. Sonographic confirmation of was performed with commercially available to disks of adhesive plastic (Beekley Spots, CT). Hemostat localization was used during
of the
was six
had
used
guided
normal for
removal
extremity
foreign
sonographic
body
guidance,
procedures.
Com-
two
in six in the
pa-
sonog-
raphy suite and two in the operating room. One patient underwent fluoroscopically guided surgical exploration after sonographic localization of the foreign body. In another patient, a retained metal needle fragment was removed under fluoroscopic guidance after sonographic localization was unsuccessful. In this case there was extensive
dissection
and
introduction
of
air
into
the
operative sonographic studies were performed polyethylene sonographic probe covers (Cone OH).
operative
with sterile Instruments,
bed.
All
latex or Solon,
December
1990
Of the 26 patients, radiographs or sonograms showed no evidence of a foreign body in six. In 1 9 patients, 21 foreign bodies were detected and localized by sonography. Sonography was unsuccessful in one case in which a retained metal needle fragment was not localized during intraoperative sonography after air was introduced into the wound after extensive dissection before sonography. Foreign bodies were detected in the feet, hands, finger, neck, thigh, knee, and calf; 1 9 of 21 foreign bodies were removed at surgery. Removal was
not
attempted
of the foreign
were not obtained. removal
AJR:155,
body
in one
patient
because
of the
small
size
(2 x 1 mm).
In another patient, a 3- by 1mm splinter was not recovered at surgery (performed with only preoperative sonographic localization). One patient underwent two localization procedures, because sonography after initial surgical exploration revealed a retained wood fragment. The 21 foreign bodies that were removed consisted of ten wood fragments, six metal needles, two pencil fragments (one radiopaque, one without radiographs), one metal BB shot, one stone, and one glass fragment (radiopaque). All of the sonographically detected foreign bodies were visualized as hyperechoic foci. Acoustic shadows were partial Fig. 1.-Retained wooden foreign body, 4 months after surgical removal failed. A and B, Transverse (A) and longitudinal (B) sonograms show echogenic foreign body (curved arrows) surrounded by hypoechoic halo of inflammation (solid straight arrows) and partial acoustic shadowing (open arrows).
Fig. 2.-Wooden
thorn. Longitudinal sonogram of hand shows wooden thorn as markedly echogenic structure (straight arrow) with nearly complete shadowing (curved arrow). Thom measured 5.6 mm in greatest length with exact correlation between preoperative sonographic through
palm
measurement
and measurement
of specimen after
recovery.
Fig.
3.-Glass.
Transverse
sonogram
of hand
shows echogenic glass foreign body (solid straight arrow) (curved arrow).
with comet-tail arrow) adjacent
reverberation to a metacarpal
artifact (open
AJR:155,
December
SONOGRAPHY
1990
IN FOREIGN
depending on the angle of the beam and the composition of the foreign body (Figs. 1 and 2). Hyperechoic comet-tail artifacts (reverberation artifacts) were seen with six metallic foreign bodies and one glass fragment (Fig. 3). Nine foreign bodies were surrounded by hypoechoic halos (Fig. 1). The halos consisted of edema (four cases), abscess (two cases), and granulation tissue (four cases), either alone or in combination. The smallest foreign body detected (and recovered) was a nonradiopaque thorn measuring 5.6 mm in length. Two wooden splinters were the thinnest foreign bodies recovered, each measuring less than 1 mm in width. Sonographically guided foreign body removal was success-
Downloaded from www.ajronline.org by 157.89.65.129 on 11/24/14 from IP address 157.89.65.129. Copyright ARRS. For personal use only; all rights reserved
or complete
ful
in all four
patients
in whom
it was
used,
including
two
needles from the feet, one needle from the knee, and one wooden pencil from the foot. No complications resulted from the sonographic localization and removal procedures. Two patients had retained wooden fragments after attempted surgical removal without sonographic guidance.
BODY
REMOVAL
1279
Discussion
Traditionally, plain films have primarily been used in the detection of soft-tissue foreign bodies. Fluoroscopy is often used for localization and guided removal. But these procedures are successful only if the foreign body is radiopaque, and radiation exposure is required. Sonography provides an excellent alternative for identifying nonradiopaque foreign bodies. In cases of radiopaque foreign bodies,
sonography
complements
the
plain
film
evaluation
by
providing accurate three-dimensional localization for preoperative planning. Knowledge of the exact location of a foreign body relative to skin surfaces, adjacent muscles, tendons, neurovascular bundles, and other vascular structures allows more controlled surgical dissection. Doppler sonography is useful if the foreign body is near a vessel. Slow, meticulous scanning technique is imperative in the detection of small foreign bodies. This is especially important
Fig. 4.-Sonograms of 19-gauge metallic needle in turkey breast. A, Longitudinal scan with needle perpendicular to ultrasound beam shows clear definition of needle (arrow). B, Sonogram with needle oblique to beam shows poorer definition of needle (arrows).
Fig. 5.-Standoff
pad. Small rectangular
tic standoff pad in place
for scanning
acous-
a finger.
Fig. 6.-Skin-marking
bead.
A, Photograph of a hand with adhesive disk and metallic bead (arrow) on hand for confirmation of skin marking. B, Transverse sonogram through thenar eminence of hand shows reverberation artifact (arrow) produced with 7.5-MHz sector transducer.
1280
in the
SHIELS
hands
and
feet,
where
there
are
many
ET AL.
probe
echogenic
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structures overlooked, skin
and where small foreign bodies can be easily and when foreign bodies do not lie parallel to the surface. When the transducer is perpendicular to the
skin,
foreign
bodies
lying
perpendicular
or oblique
to the
skin
Standoff
when
the
the
transducers are useful. Linearin the initial detection of the larger scanning area of the linear
A
C
regard,
foreign
body
in an
high-frequency
1990
of familiar
area
transducers
have
to an incision.
tissues.
bodies,
the
In this
December
proved to be valuable not only for fine measurements of foreign bodies, but also in the initial detection of the foreign bodies. The higher-frequency transducers produce more vivid echoes from the foreign bodies. Sector transducers also can be used in the initial foreign body detection, and the smaller sector transducer heads are especially useful during intraoperative localization and removal procedures. The small sector transducer is less cumbersome than a linear-array transducer and allows greater flexibility while scanning next
Both sector and linear-array array transducers are helpful foreign
accentuates
anatomy.
surface can be overlooked, only to be clearly delineated when the ultrasound beam is perpendicular to the long axis of the foreign body (Fig. 4). Although all foreign bodies in our series were echogenic, metallic foreign bodies were detected more readily than wood. The size of a foreign body contributes more to enhanced conspicuity than does foreign body composition. Small foreign bodies may be difficult to discern from surrounding
AJR:155,
visualized
gel pads
help in foreign
anatomy
in
clearer
transducer near field, enhancing The gel pads are cut with scissors
body
detection perspective
by placing out
of
the
foreign body conspicuity. or a scalpel blade to small
B
D
E
Fig. 7.-Metallic needle. A, Preoperative sonogram of foot shows echogenic metallic needle (arrow). B-E, Simulations of sonographically guided procedure for foreign body removal. B, Photograph shows sector probe on plantar surface of foot, allowing surgeon to make a lateral incision and hemostat dissection in foot for retrieval of foreign body (as opposed to an incision on plantar weight-bearing surface of foot). C, Sonogram with beam parallel to long axis of foreign body with tip of hemostat (open arrow) adjacent to tip of needle (solid arrow). D, Sonogram with transducer beam transverse to long axis of foreign body. In this plane, we see open tips of hemostat (straight arrows) adjacent to tip of needle (curved arrow) for grasping and removal. E, Plain radiograph of foot with superimposed hemostat shows lateral approach of hemostat with tips in position for sonographically guided removal.
AJA:155,
December
Fig. 8.-Pitfall
SONOGRAPHY
1990
caused
by irregulariy
IN FOREIGN
BODY
REMOVAL
1281
and par-
tially ossified cartilage. A 4-year-old boy had fallen on knee on gravel and had persistent tenderness in area of healed wound. Initial scan revealed an irregular echogenic focus with sonographic shadowing beneath skin, looking like a retained foreign body. Further scanning revealed several such
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structures
in the same area, all surrounded
by a
diskoid hypoechoic structure. A, Sonogram in sagittal plane of knee shows echogenic cutaneous scar (curved arrow) as well
as echogenic
material in subcutaneous tissue surrounded by elliptical hypoechoic zone. These specular echoes initially suspected to be a foreign body represent ossification center in diskoid cartilaginous patella. B, Corresponding lateral knee radiograph con(straight
firms
arrow)
central
speckled
patellar
ossification.
A
B
sizes for use on areas such as the hands, fingers, and neck (Fig. 5). The small standoff pads (3-6 cm long, either square or rectangular) are particularly useful in small children. Metal beads are useful for verification of skin-marker position. Metal beads attached to adhesive disks used for lesion localization in CT-guided biopsies and drainage procedures (Fig.
6A) are ideal
sonographic
markers.
The
beads
are sono-
graphically visualized over the marked area, casting either an acoustic shadow or ring-down artifact beneath the bead (Fig. 6B). The adhesive disk transmits sound waves and does not obscure visualization of the underlying anatomy or foreign body. The adhesive disk is easily removed and replaced if repeated marking and verification are necessary. Standoff pads are used with bead verification. Sonographic guidance of dissection and foreign body removal allows tailoring of the surgical approach, reducing the
size of incision and depth of dissection
(Fig. 7). Preoperative
(or preincision) sonography is an essential element in successful sonographic detection, localization, and guided removal of foreign bodies. As demonstrated in our only case of unsuccessful detection, air introduced into tissues adjacent to a foreign body during dissection can obscure sonographic visualization of the foreign body. Care must be taken to avoid pitfalls in distinguishing foreign bodies from other body tissue such as ossified cartilage (Fig. 8), keratin plugs [3], and scar tissue. A combination of longitudinal and transverse scanning planes facilitates removal. Scanning with the ultrasound beam aligned with the long axis of a hemostat and the foreign body is the fastest way to guide the hemostat to the tip of the foreign body (Fig. 7C). If the removal attempt with longitudinal
scanning is unsuccessful, after the closed hemostat is visualized near the tip of the foreign body, transverse scanning best visualizes the tip of the foreign body as well as the two tips of the hemostat, in open and closed positions (Fig. 7D). Skin incisions and dissections were performed by surgeons in the four sonographically guided removal cases. With experience and practice, including practice using beef tongue and turkey breast (Shiels et al., presented at the annual meeting of the Radiological Society of North American, November 1 989), the time required for successful sonographically guided removal decreased. Our first attempt took nearly 1 hr from initial skin incision to successful removal. With better preoperative planning, improved communication with the surgeons, and practice, subsequent foreign bodies were removed in 1 1 mm, 3 mm, and 2 mm, respectively. Sonographically guided foreign body removal is accomplished most easily and quickly when one physician performs sonography and hemostat removal of the foreign body simultaneously. ACKNOWLEDGMENTS We thank Juanita Hunter and Theresa Ricke for help in manuscript preparation and Coming Benton for editorial support.
REFERENCES 1 . Fomage BD, Schemberg FJ. Sonographic diagnosis of foreign bodies the distal extremities (case report). AJR 1986;i47:567-569 2. Fomage BD, Schemberg FJ. Sonographic pro-operative foreign body in the hand. J Ultrasound Med 1987;6:2i7-2i9
3. Gooding
GAW, Hardiman
T, Sumers
Sonography of the hand and foot Med 1987;6:441-447
4. Gordon D. Non-metallic
localization
of of a
M, Stess A, Graf P, Grunfeld C. body detection. J Ultrasound
in foreign
foreign bodies (letter). Br J Radio!
1985:58:574
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This article has been cited by: 1. Mohamed Jarraya, Daichi Hayashi, Richard V. de Villiers, Frank W. Roemer, Akira M. Murakami, Alda Cossi, Ali Guermazi. 2014. Multimodality Imaging of Foreign Bodies of the Musculoskeletal System. American Journal of Roentgenology 203:1, W92W102. [Abstract] [Full Text] [PDF] [PDF Plus] [Supplemental Material] 2. Wailliam W. Lee, Daniel J. Kim. 2014. Migrating Sternal Rod: Ultrasound Identification of an Unusual Soft Tissue Foreign Body. The Journal of Emergency Medicine 46, e117-e120. [CrossRef] 3. L. Kempf, K.F. Braun, J. Neu. 2014. Augenbrauenplatzwunde mit übersehenem Fremdkörper. Der Unfallchirurg 117, 162-166. [CrossRef] 4. Mazen E. Iskandar, Simon D. Eiref, I. Michael Leitman. 2013. The Iliad and the Odyssey of metallic foreign body extraction: commentary on “Novel methods of removing metallic foreign body from human soft tissue: a report of 7390 cases”. Journal of Surgical Research 185, e31-e33. [CrossRef] 5. O. Kenechi Nwawka, Nii-Kabu Kabutey, Christopher M. Locke, Ilse Castro-Aragon, Ducksoo Kim. 2013. Ultrasound-guided Needle Localization to Aid Foreign Body Removal in Pediatric Patients. The Journal of Foot and Ankle Surgery . [CrossRef] 6. Sui-Yi Chao, Tai-Chung Chern, I-Ming Jou, Yao-Lung Kuo. 2013. Ultrasonography for detecting a hog bristle in a finger: a case report and literature review. International Wound Journal n/a-n/a. [CrossRef] 7. Mohamed Ragab Nouh, Ahmed Mohamed Sabry Nasr, Mohamed Osama El-Shebeny. 2013. Wooden splinter-induced extremity injuries: Accuracy of MRI evaluation. The Egyptian Journal of Radiology and Nuclear Medicine 44, 573-579. [CrossRef] 8. Guang-Fu Xing, Chang-Wen Shi, He-Xiang Qian, Xian-Ju Qin. 2013. Novel methods of removing metallic foreign body from human soft tissue: a report of 7390 cases. Journal of Surgical Research 183, 337-340. [CrossRef] 9. Michael J. Callahan. 2013. Musculoskeletal ultrasonography of the lower extremities in infants and children. Pediatric Radiology 43, 8-22. [CrossRef] 10. Mahesh Thapa, Jack-Ngnia Vo, William E. Shiels. 2013. Ultrasound-guided musculoskeletal procedures in children. Pediatric Radiology 43, 55-60. [CrossRef] 11. Seong Yong So, Hyun-joo Kim, Deuk Lin Choi, Seong Sook Hong, Yun-Woo Chang, Sung Tae Park. 2013. MRI Findings of Intramuscular Foreign Body Injection: A Case Report. Journal of the Korean Society of Magnetic Resonance in Medicine 17, 59. [CrossRef] 12. R.F.W. Lloyd, C. Feeney. 2011. Adolescent hip pain: the needle in the haystack. A case report. Physiotherapy 97, 354-356. [CrossRef] 13. Adam S. Young, William E. Shiels, James W. Murakami, Brian D. Coley, Mark J. Hogan. 2010. Self-embedding Behavior: Radiologic Management of Self-inserted Soft-Tissue Foreign Bodies 1. Radiology 257, 233-239. [CrossRef] 14. Jordan K. Close, William E. Shiels, Jill A. Foster, Dwight A. Powell. 2009. Percutaneous Ultrasound-Guided Intraorbital Foreign Body Removal. Ophthalmic Plastic & Reconstructive Surgery 25, 335-337. [CrossRef] 15. Leonardo Callegari, Anna Leonardi, Amedeo Bini, Chiara Sabato, Paolo Nicotera, Emanuela Spano’, Davide Mariani, Eugenio A. Genovese, Carlo Fugazzola. 2009. Ultrasound-guided removal of foreign bodies: personal experience. European Radiology 19, 1273-1279. [CrossRef] 16. Stephanie A. Creel, Gandikota Girish, David A. Jamadar, Yoav Morag, Jon A. Jacobson. 2009. Sonographic surface localization of subcutaneous foreign bodies and masses. Journal of Clinical Ultrasound 37:10.1002/jcu.v37:3, 158-160. [CrossRef] 17. S.Y. Ng, A.K. Songra, P.F. Bradley. 2003. A new approach using intraoperative ultrasound imaging for the localization and removal of multiple foreign bodies in the neck. International Journal of Oral and Maxillofacial Surgery 32, 433-436. [CrossRef] 18. L. Kimberlee Horton, Jon A. Jacobson, Alex Powell, David P. Fessell, Curtis W. Hayes. 2001. Sonography and Radiography of Soft-Tissue Foreign Bodies. American Journal of Roentgenology 176:5, 1155-1159. [Citation] [Full Text] [PDF] [PDF Plus]
1277
Localization and Guided Removal of Soft-Tissue Foreign Bodies with Sonography
William E. Shiels 1113 Diane S. Babcock1 James L. Wilson2 Reed A. Burch2
Sonography was used to detect, localize, and guide removal of foreign bodies in the soft tissues of the extremities and neck. Twenty localization procedures were performed in 19 patients (12 children and seven adults) with 21 foreign bodies including wood, glass, stone, metal, and lead pencil. Localization was accomplished by using anatomic landmarks, ink marks on the skin, and needle and hemostat markers. Localization was facilitated by the use of small standoff pads that were cut for use on small surfaces. The foreign bodies were visualized as hyperechoic foci with acoustic shadows that were partial or complete depending on the angle of insonation and foreign body composition. Hyperechoic comet-tail artifacts (reverberation artifacts) were seen with six metallic foreign bodies and one glass fragment. Nine foreign bodies were surrounded by hypoechoic halos caused by edema, abscess, or granulation tissue. A slow meticubus scanning technique and high-frequency transducer helped in detection of small foreign bodies. Sonographically guided removal of the foreign body was successful in all four patients in whom it was attempted. Scanning with the ultrasound beam parallel to the long axis of the hemostat and the foreign body was the fastest way to guide the hemostat to the tip of a foreign body. The procedure was accomplished most easily and quickly when one physician performed sonography and hemostat removal of the foreign body simultaneously. Our experience with these cases indicates that sonography is a useful tool in the localization and removal of soft-tissue foreign bodies. AJR
Received February 27, 1990; accepted vision June 29, 1990.
after re-
The opinions or assertions contained herein are the private views of the authors and are not to be construed as official or as reflecting the views of the Department of the Army or the Department of
Defense. Presented at the annual meeting of the Society for Pediatric Radiology, San Antonio, TX, April 1989. 1 Department of Radiology, Children’s Hospital Center, and the Departments of Radiology and Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH 45229-2899. 2 Tripler Army Medical Center, Honolulu, HI
155:1277-1281,
December
1990
Soft-tissue foreign bodies are a common clinical problem in both children and adults. Traditionally, radiographs have been used to identify radiopaque foreign bodies and fluoroscopy has been used for guidance during surgical removal. Recent reports have demonstrated the usefulness of sonography in the detection, preoperative localization, and confirmation of surgical retrieval of foreign bodies in the distal extremities [1-4]. We report a series of patients in whom sonography was successfully used for detection, localization, and removal of soft-tissue foreign bodies in the extremities and the neck.
Materials
and
Methods
Medical
96859-5000. Present address: Department of Radiology, Walter Reed Army Medical Center, Washington, DC 20307-5001. Address reprint requests toW. E. 3
Shiels II. 0361 -803X/90/i
556-1 277
Twenty-six patients were referred for sonography because bodies in soft-tissue between March 1 986 and May 1 990. surgeons
either
before,
during,
or
after
exploration
for
of possible retention of foreign The patients were referred by
possible
soft-tissue
foreign
bodies.
The 1 9 males and seven females were 1 -37 years old (mean, 13 years). Nineteen patients were between 1 and 17 years old, and seven were between 22 and 37 years In 24 patients, plain radiographs were obtained before sonography. In two patients, with a known wooden splinter in the thigh and one with a lead pencil fragment in the no radiographs were obtained. Surgical removal had been attempted unsuccessfully patients.
of the
old. one hand, in five
SHIELS
ET AL.
with Acuson 1 28 (Mountain View, CA); 4, or ATL-Mark 300 (Bothell, WA); and (Cleveland, OH) systems, using 5.0-, 7.5-, and 10.0Commercially available standoff pads (Kitecko, 3M,
Results
1278
Sonograms ATL-Ultramark Picker
were obtained 8, ATL-Mark
Microview
MHz transducers. Roseville,
MN,
and
Aquaflex,
Parker
Laboratories,
Inc.,
Orange,
NJ)
Downloaded from www.ajronline.org by 157.89.65.129 on 11/24/14 from IP address 157.89.65.129. Copyright ARRS. For personal use only; all rights reserved
were used to provide
adequate visualization of the skin and superficial Preoperative localization was performed by marking the
soft tissues. skin
with
with
permanent
ink markers.
skin-marker positioning metal beads attached Beekley Corp., Bristol, four
intraoperative
parison
images
Imaging tients.
Needle
localization
was
performed
1 9- or 27-gauge
either
sonographically
of the opposite
guidance
Four
needles. Sonographic confirmation of was performed with commercially available to disks of adhesive plastic (Beekley Spots, CT). Hemostat localization was used during
of the
was six
had
used
guided
normal for
removal
extremity
foreign
sonographic
body
guidance,
procedures.
Com-
two
in six in the
pa-
sonog-
raphy suite and two in the operating room. One patient underwent fluoroscopically guided surgical exploration after sonographic localization of the foreign body. In another patient, a retained metal needle fragment was removed under fluoroscopic guidance after sonographic localization was unsuccessful. In this case there was extensive
dissection
and
introduction
of
air
into
the
operative sonographic studies were performed polyethylene sonographic probe covers (Cone OH).
operative
with sterile Instruments,
bed.
All
latex or Solon,
December
1990
Of the 26 patients, radiographs or sonograms showed no evidence of a foreign body in six. In 1 9 patients, 21 foreign bodies were detected and localized by sonography. Sonography was unsuccessful in one case in which a retained metal needle fragment was not localized during intraoperative sonography after air was introduced into the wound after extensive dissection before sonography. Foreign bodies were detected in the feet, hands, finger, neck, thigh, knee, and calf; 1 9 of 21 foreign bodies were removed at surgery. Removal was
not
attempted
of the foreign
were not obtained. removal
AJR:155,
body
in one
patient
because
of the
small
size
(2 x 1 mm).
In another patient, a 3- by 1mm splinter was not recovered at surgery (performed with only preoperative sonographic localization). One patient underwent two localization procedures, because sonography after initial surgical exploration revealed a retained wood fragment. The 21 foreign bodies that were removed consisted of ten wood fragments, six metal needles, two pencil fragments (one radiopaque, one without radiographs), one metal BB shot, one stone, and one glass fragment (radiopaque). All of the sonographically detected foreign bodies were visualized as hyperechoic foci. Acoustic shadows were partial Fig. 1.-Retained wooden foreign body, 4 months after surgical removal failed. A and B, Transverse (A) and longitudinal (B) sonograms show echogenic foreign body (curved arrows) surrounded by hypoechoic halo of inflammation (solid straight arrows) and partial acoustic shadowing (open arrows).
Fig. 2.-Wooden
thorn. Longitudinal sonogram of hand shows wooden thorn as markedly echogenic structure (straight arrow) with nearly complete shadowing (curved arrow). Thom measured 5.6 mm in greatest length with exact correlation between preoperative sonographic through
palm
measurement
and measurement
of specimen after
recovery.
Fig.
3.-Glass.
Transverse
sonogram
of hand
shows echogenic glass foreign body (solid straight arrow) (curved arrow).
with comet-tail arrow) adjacent
reverberation to a metacarpal
artifact (open
AJR:155,
December
SONOGRAPHY
1990
IN FOREIGN
depending on the angle of the beam and the composition of the foreign body (Figs. 1 and 2). Hyperechoic comet-tail artifacts (reverberation artifacts) were seen with six metallic foreign bodies and one glass fragment (Fig. 3). Nine foreign bodies were surrounded by hypoechoic halos (Fig. 1). The halos consisted of edema (four cases), abscess (two cases), and granulation tissue (four cases), either alone or in combination. The smallest foreign body detected (and recovered) was a nonradiopaque thorn measuring 5.6 mm in length. Two wooden splinters were the thinnest foreign bodies recovered, each measuring less than 1 mm in width. Sonographically guided foreign body removal was success-
Downloaded from www.ajronline.org by 157.89.65.129 on 11/24/14 from IP address 157.89.65.129. Copyright ARRS. For personal use only; all rights reserved
or complete
ful
in all four
patients
in whom
it was
used,
including
two
needles from the feet, one needle from the knee, and one wooden pencil from the foot. No complications resulted from the sonographic localization and removal procedures. Two patients had retained wooden fragments after attempted surgical removal without sonographic guidance.
BODY
REMOVAL
1279
Discussion
Traditionally, plain films have primarily been used in the detection of soft-tissue foreign bodies. Fluoroscopy is often used for localization and guided removal. But these procedures are successful only if the foreign body is radiopaque, and radiation exposure is required. Sonography provides an excellent alternative for identifying nonradiopaque foreign bodies. In cases of radiopaque foreign bodies,
sonography
complements
the
plain
film
evaluation
by
providing accurate three-dimensional localization for preoperative planning. Knowledge of the exact location of a foreign body relative to skin surfaces, adjacent muscles, tendons, neurovascular bundles, and other vascular structures allows more controlled surgical dissection. Doppler sonography is useful if the foreign body is near a vessel. Slow, meticulous scanning technique is imperative in the detection of small foreign bodies. This is especially important
Fig. 4.-Sonograms of 19-gauge metallic needle in turkey breast. A, Longitudinal scan with needle perpendicular to ultrasound beam shows clear definition of needle (arrow). B, Sonogram with needle oblique to beam shows poorer definition of needle (arrows).
Fig. 5.-Standoff
pad. Small rectangular
tic standoff pad in place
for scanning
acous-
a finger.
Fig. 6.-Skin-marking
bead.
A, Photograph of a hand with adhesive disk and metallic bead (arrow) on hand for confirmation of skin marking. B, Transverse sonogram through thenar eminence of hand shows reverberation artifact (arrow) produced with 7.5-MHz sector transducer.
1280
in the
SHIELS
hands
and
feet,
where
there
are
many
ET AL.
probe
echogenic
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structures overlooked, skin
and where small foreign bodies can be easily and when foreign bodies do not lie parallel to the surface. When the transducer is perpendicular to the
skin,
foreign
bodies
lying
perpendicular
or oblique
to the
skin
Standoff
when
the
the
transducers are useful. Linearin the initial detection of the larger scanning area of the linear
A
C
regard,
foreign
body
in an
high-frequency
1990
of familiar
area
transducers
have
to an incision.
tissues.
bodies,
the
In this
December
proved to be valuable not only for fine measurements of foreign bodies, but also in the initial detection of the foreign bodies. The higher-frequency transducers produce more vivid echoes from the foreign bodies. Sector transducers also can be used in the initial foreign body detection, and the smaller sector transducer heads are especially useful during intraoperative localization and removal procedures. The small sector transducer is less cumbersome than a linear-array transducer and allows greater flexibility while scanning next
Both sector and linear-array array transducers are helpful foreign
accentuates
anatomy.
surface can be overlooked, only to be clearly delineated when the ultrasound beam is perpendicular to the long axis of the foreign body (Fig. 4). Although all foreign bodies in our series were echogenic, metallic foreign bodies were detected more readily than wood. The size of a foreign body contributes more to enhanced conspicuity than does foreign body composition. Small foreign bodies may be difficult to discern from surrounding
AJR:155,
visualized
gel pads
help in foreign
anatomy
in
clearer
transducer near field, enhancing The gel pads are cut with scissors
body
detection perspective
by placing out
of
the
foreign body conspicuity. or a scalpel blade to small
B
D
E
Fig. 7.-Metallic needle. A, Preoperative sonogram of foot shows echogenic metallic needle (arrow). B-E, Simulations of sonographically guided procedure for foreign body removal. B, Photograph shows sector probe on plantar surface of foot, allowing surgeon to make a lateral incision and hemostat dissection in foot for retrieval of foreign body (as opposed to an incision on plantar weight-bearing surface of foot). C, Sonogram with beam parallel to long axis of foreign body with tip of hemostat (open arrow) adjacent to tip of needle (solid arrow). D, Sonogram with transducer beam transverse to long axis of foreign body. In this plane, we see open tips of hemostat (straight arrows) adjacent to tip of needle (curved arrow) for grasping and removal. E, Plain radiograph of foot with superimposed hemostat shows lateral approach of hemostat with tips in position for sonographically guided removal.
AJA:155,
December
Fig. 8.-Pitfall
SONOGRAPHY
1990
caused
by irregulariy
IN FOREIGN
BODY
REMOVAL
1281
and par-
tially ossified cartilage. A 4-year-old boy had fallen on knee on gravel and had persistent tenderness in area of healed wound. Initial scan revealed an irregular echogenic focus with sonographic shadowing beneath skin, looking like a retained foreign body. Further scanning revealed several such
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structures
in the same area, all surrounded
by a
diskoid hypoechoic structure. A, Sonogram in sagittal plane of knee shows echogenic cutaneous scar (curved arrow) as well
as echogenic
material in subcutaneous tissue surrounded by elliptical hypoechoic zone. These specular echoes initially suspected to be a foreign body represent ossification center in diskoid cartilaginous patella. B, Corresponding lateral knee radiograph con(straight
firms
arrow)
central
speckled
patellar
ossification.
A
B
sizes for use on areas such as the hands, fingers, and neck (Fig. 5). The small standoff pads (3-6 cm long, either square or rectangular) are particularly useful in small children. Metal beads are useful for verification of skin-marker position. Metal beads attached to adhesive disks used for lesion localization in CT-guided biopsies and drainage procedures (Fig.
6A) are ideal
sonographic
markers.
The
beads
are sono-
graphically visualized over the marked area, casting either an acoustic shadow or ring-down artifact beneath the bead (Fig. 6B). The adhesive disk transmits sound waves and does not obscure visualization of the underlying anatomy or foreign body. The adhesive disk is easily removed and replaced if repeated marking and verification are necessary. Standoff pads are used with bead verification. Sonographic guidance of dissection and foreign body removal allows tailoring of the surgical approach, reducing the
size of incision and depth of dissection
(Fig. 7). Preoperative
(or preincision) sonography is an essential element in successful sonographic detection, localization, and guided removal of foreign bodies. As demonstrated in our only case of unsuccessful detection, air introduced into tissues adjacent to a foreign body during dissection can obscure sonographic visualization of the foreign body. Care must be taken to avoid pitfalls in distinguishing foreign bodies from other body tissue such as ossified cartilage (Fig. 8), keratin plugs [3], and scar tissue. A combination of longitudinal and transverse scanning planes facilitates removal. Scanning with the ultrasound beam aligned with the long axis of a hemostat and the foreign body is the fastest way to guide the hemostat to the tip of the foreign body (Fig. 7C). If the removal attempt with longitudinal
scanning is unsuccessful, after the closed hemostat is visualized near the tip of the foreign body, transverse scanning best visualizes the tip of the foreign body as well as the two tips of the hemostat, in open and closed positions (Fig. 7D). Skin incisions and dissections were performed by surgeons in the four sonographically guided removal cases. With experience and practice, including practice using beef tongue and turkey breast (Shiels et al., presented at the annual meeting of the Radiological Society of North American, November 1 989), the time required for successful sonographically guided removal decreased. Our first attempt took nearly 1 hr from initial skin incision to successful removal. With better preoperative planning, improved communication with the surgeons, and practice, subsequent foreign bodies were removed in 1 1 mm, 3 mm, and 2 mm, respectively. Sonographically guided foreign body removal is accomplished most easily and quickly when one physician performs sonography and hemostat removal of the foreign body simultaneously. ACKNOWLEDGMENTS We thank Juanita Hunter and Theresa Ricke for help in manuscript preparation and Coming Benton for editorial support.
REFERENCES 1 . Fomage BD, Schemberg FJ. Sonographic diagnosis of foreign bodies the distal extremities (case report). AJR 1986;i47:567-569 2. Fomage BD, Schemberg FJ. Sonographic pro-operative foreign body in the hand. J Ultrasound Med 1987;6:2i7-2i9
3. Gooding
GAW, Hardiman
T, Sumers
Sonography of the hand and foot Med 1987;6:441-447
4. Gordon D. Non-metallic
localization
of of a
M, Stess A, Graf P, Grunfeld C. body detection. J Ultrasound
in foreign
foreign bodies (letter). Br J Radio!
1985:58:574
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