American Journal of Emergency Medicine xxx (2014) xxx–xxx
Contents lists available at ScienceDirect
American Journal of Emergency Medicine journal homepage: www.elsevier.com/locate/ajem
Case Report
A case series featuring soft tissue foreign body removal with magnet in ED settings Abstract Retained foreign particles is a common reason for emergency department visits. Although most foreign bodies are never harmful, they have to be removed when they cause pain, neurologic symptoms, vascular compression, function loss, sterile abscesses or granulomas, and infection. In this series, the authors document 5 cases of metallic foreign body impaction in the soft tissue and highlight the challenges encountered in their management. Consents were obtained from the patients before the case reports. Penetrating injuries and suspected retained foreign bodies are a common reason for emergency department (ED) visits. Besides high incidence, retained foreign bodies are responsible for 14% of lawsuits and 5% of legal settlements [1]. Foreign bodies should be removed from wounds during the primary wound management stage whenever possible. Metallic fragments could be identified and localized by conventional radiography, computed tomography (CT), sonography, x-ray image intensifier, or electromagnetic metal detector [2,3]. Foreign bodies come in many different shapes and sizes and typically consist of wood, glass, and metallic splinters [4]. A 25-year-old man presented with a 1-hour history of left-hand finger swelling due to injury with a piece of iron. Foreign body could be palpable with manual inspection. Magnet moved toward the skin over the foreign body. The region, where most of the magnet power sense, was sterilized and anesthetized. The wound was extended 3 mm with forceps. After incision of 2 mm, metallic object was leaving the wound spontaneously, and it was stuck to the magnet (Fig. 1A and B). This process was completed in 6 minutes. An 18-year-old man was admitted to ED with piece of metal stuck on forearm. Foreign body could not be palpated, but it could be determinated with magnet. The field, where was labeled with magnet, was sterilized and anesthetized. The wound was enlarged by 3 mm incision by using forceps. As soon as the magnet came close to the wound, 2 mm metal body adhered to the magnet, and this process was performed in 5 minutes (Fig. 2A and B). A 35-year-old man was presented to the ED with a foreign body in the hand. It was plunged to the tissue for a year ago. Palpable foreign body was located with magnet. The incisions made were between 1 and 2 cm, and the magnet was put into the subcutaneous tissue to check the direction of dissection. Although the wound was expanded with forceps and local anesthetize was applied, the foreign body did not separate from the wound. It was dragged from the tissue with forceps within 18 minutes (Fig. 3A and B). A 55-year-old female was admitted to ED with stuck foreign body on forehead. Manual examination of foreign body could not be determined by palpation. While trying to detect foreign body by using magnet, it was separated from the wound. This process, which was
Fig. 1. A, Detection of foreign body with magnet. B, Foreign body stuck to the magnet.
0735-6757/$ – see front matter © 2014 Elsevier Inc. All rights reserved.
Please cite this article as: Sarıhan A, Can Ç, A case series featuring soft tissue foreign body removal with magnet in ED settings, Am J Emerg Med (2014), http://dx.doi.org/10.1016/j.ajem.2014.02.009
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A. Sarıhan, Ç. Can / American Journal of Emergency Medicine xxx (2014) xxx–xxx
Fig. 3. A, Magnetic property reinforced industrial magnet. B, Metal objects were removed with the help of the magnet.
Fig. 2. A, Foreign body was detected by magnet on the elbow localization. B, Magnet separated the attached object from tissue.
performed without anesthesia or incision, was lasted 10 seconds (Fig. 4A and B). A 45-year-old man was presented to ED with a piece of metal scraping on hand for 2 weeks ago. Pain in the hand does not exceed and increased with motion within days. The foreign bodies could be sensed with palpation and was detected with magnet. Local anesthesia was applied to the region of the foreign body, and the 3 mm incision was performed. The foreign body was separated from the wound by magnet (Fig. 5A and B). This process took 4 minutes. Surgical procedures were conducted with these cases without local anesthesia but in case three, the authors used lidocaine and 1:80,000 adrenaline for incision. In the literature, there are many case examples about extraction of metallic foreign bodies from tissues by using magnet [5], but there was not sufficient number of notifications about removal of foreign bodies in ED settings. In these series, the authors document 5 cases of foreign body impaction in the superficial soft tissue and highlight the challenges encountered in their management by using magnet.
In this case series we determined that if the foreign body remains a very long time in the tissue, the removal process has a higher failure rate with magnet as in case 3. Interestingly, during the examination of case 4, the foreign body was separated from tissue spontaneously without any incision in 10 seconds. Removal of the foreign body might be fast and efficient because of the thin subcutaneous tissue of the face and the small size of the foreign body. Finding a foreign body could be quite challenging because most superficial foreign bodies are removed by the patient, leaving the physician to deal with deeper and larger foreign bodies. If unrecognized, a retained foreign body may lead to complications such as inflammation, infection, toxic reactions, and foreign body granulomas. A magnet could help locate the metal object more quickly, potentially reducing risks as mentioned above [4]. Subcutaneous foreign metallic object is attempted with magnet. It could be substituted for x-ray, ultrasonography, CT, and magnetic resonance as it is an easy and cheap method. Enlarging the wound entrance, after contact with the magnet, the object could be dissected out or even pulled out with the magnet [6]. Magnet is easy to use and inexpensive. Identifying the location of the foreign body by using the magnet is fast. Metallic objects can be removed by small incisions. Therefore, the scar tissue content is reduced [7].
Please cite this article as: Sarıhan A, Can Ç, A case series featuring soft tissue foreign body removal with magnet in ED settings, Am J Emerg Med (2014), http://dx.doi.org/10.1016/j.ajem.2014.02.009
A. Sarıhan, Ç. Can / American Journal of Emergency Medicine xxx (2014) xxx–xxx
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Fig. 4. A, Wound in the forehead. B, Foreign body stuck to the magnet spontaneously. Fig. 5. A, Foreign body was detected with the magnet. B, Foreign body adhered to the magnet.
Metallic foreign bodies create hilliness out of the skin due to their magnetic attraction. In this way, they could be easily located and extracted [5]. In cases 2 and 4, because of the thin surface of the skin and subcutaneous soft tissue, the extraction process was easier than other cases. But in case 3, the removal process was difficult because the foreign body remained too long in the tissue for magnet extraction. In the light of these cases, magnet is used not only to deprive the foreign metallic bodies, but also it is suitable for the detection of foreign body location in ED settings. Magnet usage could easily determine and remove the metallic foreign bodies. It is practical to use and cost effective. Furthermore, magnet is reducing the need for anesthetic agent, size of incision, and scar tissue. As a result, magnet would be a good choice in ED settings, for foreign body removal from tissues.
Aydın Sarıhan MD Department of Emergency Medicine Emergency Medicine Specialist Basaksehir State Hospital Istanbul, Turkey
Çağdaş Can MD Department of Emergency Medicine Emergency Medicine Specialist Merkezefendi State Hospital Manisa, Turkey E-mail address: [email protected] http://dx.doi.org/10.1016/j.ajem.2014.02.009 References [1] Giu H, Yang H, Shen S, et al. Image-guided surgical navigation for removal of foreign bodies in the deep maxillofacial region. J Oral Maxillofac Surg 2013;71:1563–71. [2] Veselco M, Trobec R. Intraoperative localization of retained metallic fragments in missile wounds. J Trauma 2000;49:1052. [3] Öztürk AZ, İbrahim A. Late diagnosed nasal foreign body. Tr J Emerg Med 2005;5:86–8. [4] Kadish HA, Corneli HM. Removel of nasal foreign bodies in the pediatric population. Am J Emerg Med 1997;15:54–6. [5] Dolderer JH, Kelly JL, Morrison WA, et al. Foreign-body retrieval using a rare earth magnet. Plast Reconstr Surg 2004;113:1869–70. [6] Blankenship RB, Baker T. Imaging modalities in wounds and superficial skin infections. Emerg Med Clin North Am 2007;25:223–34. [7] Çakır B, Akan M, Yıldırım S, et al. Localization and removal of ferromagnetic foreign bodies by magnet. Ann Plast Surg 2002;49:541–4.
Please cite this article as: Sarıhan A, Can Ç, A case series featuring soft tissue foreign body removal with magnet in ED settings, Am J Emerg Med (2014), http://dx.doi.org/10.1016/j.ajem.2014.02.009
Contents lists available at ScienceDirect
American Journal of Emergency Medicine journal homepage: www.elsevier.com/locate/ajem
Case Report
A case series featuring soft tissue foreign body removal with magnet in ED settings Abstract Retained foreign particles is a common reason for emergency department visits. Although most foreign bodies are never harmful, they have to be removed when they cause pain, neurologic symptoms, vascular compression, function loss, sterile abscesses or granulomas, and infection. In this series, the authors document 5 cases of metallic foreign body impaction in the soft tissue and highlight the challenges encountered in their management. Consents were obtained from the patients before the case reports. Penetrating injuries and suspected retained foreign bodies are a common reason for emergency department (ED) visits. Besides high incidence, retained foreign bodies are responsible for 14% of lawsuits and 5% of legal settlements [1]. Foreign bodies should be removed from wounds during the primary wound management stage whenever possible. Metallic fragments could be identified and localized by conventional radiography, computed tomography (CT), sonography, x-ray image intensifier, or electromagnetic metal detector [2,3]. Foreign bodies come in many different shapes and sizes and typically consist of wood, glass, and metallic splinters [4]. A 25-year-old man presented with a 1-hour history of left-hand finger swelling due to injury with a piece of iron. Foreign body could be palpable with manual inspection. Magnet moved toward the skin over the foreign body. The region, where most of the magnet power sense, was sterilized and anesthetized. The wound was extended 3 mm with forceps. After incision of 2 mm, metallic object was leaving the wound spontaneously, and it was stuck to the magnet (Fig. 1A and B). This process was completed in 6 minutes. An 18-year-old man was admitted to ED with piece of metal stuck on forearm. Foreign body could not be palpated, but it could be determinated with magnet. The field, where was labeled with magnet, was sterilized and anesthetized. The wound was enlarged by 3 mm incision by using forceps. As soon as the magnet came close to the wound, 2 mm metal body adhered to the magnet, and this process was performed in 5 minutes (Fig. 2A and B). A 35-year-old man was presented to the ED with a foreign body in the hand. It was plunged to the tissue for a year ago. Palpable foreign body was located with magnet. The incisions made were between 1 and 2 cm, and the magnet was put into the subcutaneous tissue to check the direction of dissection. Although the wound was expanded with forceps and local anesthetize was applied, the foreign body did not separate from the wound. It was dragged from the tissue with forceps within 18 minutes (Fig. 3A and B). A 55-year-old female was admitted to ED with stuck foreign body on forehead. Manual examination of foreign body could not be determined by palpation. While trying to detect foreign body by using magnet, it was separated from the wound. This process, which was
Fig. 1. A, Detection of foreign body with magnet. B, Foreign body stuck to the magnet.
0735-6757/$ – see front matter © 2014 Elsevier Inc. All rights reserved.
Please cite this article as: Sarıhan A, Can Ç, A case series featuring soft tissue foreign body removal with magnet in ED settings, Am J Emerg Med (2014), http://dx.doi.org/10.1016/j.ajem.2014.02.009
2
A. Sarıhan, Ç. Can / American Journal of Emergency Medicine xxx (2014) xxx–xxx
Fig. 3. A, Magnetic property reinforced industrial magnet. B, Metal objects were removed with the help of the magnet.
Fig. 2. A, Foreign body was detected by magnet on the elbow localization. B, Magnet separated the attached object from tissue.
performed without anesthesia or incision, was lasted 10 seconds (Fig. 4A and B). A 45-year-old man was presented to ED with a piece of metal scraping on hand for 2 weeks ago. Pain in the hand does not exceed and increased with motion within days. The foreign bodies could be sensed with palpation and was detected with magnet. Local anesthesia was applied to the region of the foreign body, and the 3 mm incision was performed. The foreign body was separated from the wound by magnet (Fig. 5A and B). This process took 4 minutes. Surgical procedures were conducted with these cases without local anesthesia but in case three, the authors used lidocaine and 1:80,000 adrenaline for incision. In the literature, there are many case examples about extraction of metallic foreign bodies from tissues by using magnet [5], but there was not sufficient number of notifications about removal of foreign bodies in ED settings. In these series, the authors document 5 cases of foreign body impaction in the superficial soft tissue and highlight the challenges encountered in their management by using magnet.
In this case series we determined that if the foreign body remains a very long time in the tissue, the removal process has a higher failure rate with magnet as in case 3. Interestingly, during the examination of case 4, the foreign body was separated from tissue spontaneously without any incision in 10 seconds. Removal of the foreign body might be fast and efficient because of the thin subcutaneous tissue of the face and the small size of the foreign body. Finding a foreign body could be quite challenging because most superficial foreign bodies are removed by the patient, leaving the physician to deal with deeper and larger foreign bodies. If unrecognized, a retained foreign body may lead to complications such as inflammation, infection, toxic reactions, and foreign body granulomas. A magnet could help locate the metal object more quickly, potentially reducing risks as mentioned above [4]. Subcutaneous foreign metallic object is attempted with magnet. It could be substituted for x-ray, ultrasonography, CT, and magnetic resonance as it is an easy and cheap method. Enlarging the wound entrance, after contact with the magnet, the object could be dissected out or even pulled out with the magnet [6]. Magnet is easy to use and inexpensive. Identifying the location of the foreign body by using the magnet is fast. Metallic objects can be removed by small incisions. Therefore, the scar tissue content is reduced [7].
Please cite this article as: Sarıhan A, Can Ç, A case series featuring soft tissue foreign body removal with magnet in ED settings, Am J Emerg Med (2014), http://dx.doi.org/10.1016/j.ajem.2014.02.009
A. Sarıhan, Ç. Can / American Journal of Emergency Medicine xxx (2014) xxx–xxx
3
Fig. 4. A, Wound in the forehead. B, Foreign body stuck to the magnet spontaneously. Fig. 5. A, Foreign body was detected with the magnet. B, Foreign body adhered to the magnet.
Metallic foreign bodies create hilliness out of the skin due to their magnetic attraction. In this way, they could be easily located and extracted [5]. In cases 2 and 4, because of the thin surface of the skin and subcutaneous soft tissue, the extraction process was easier than other cases. But in case 3, the removal process was difficult because the foreign body remained too long in the tissue for magnet extraction. In the light of these cases, magnet is used not only to deprive the foreign metallic bodies, but also it is suitable for the detection of foreign body location in ED settings. Magnet usage could easily determine and remove the metallic foreign bodies. It is practical to use and cost effective. Furthermore, magnet is reducing the need for anesthetic agent, size of incision, and scar tissue. As a result, magnet would be a good choice in ED settings, for foreign body removal from tissues.
Aydın Sarıhan MD Department of Emergency Medicine Emergency Medicine Specialist Basaksehir State Hospital Istanbul, Turkey
Çağdaş Can MD Department of Emergency Medicine Emergency Medicine Specialist Merkezefendi State Hospital Manisa, Turkey E-mail address: [email protected] http://dx.doi.org/10.1016/j.ajem.2014.02.009 References [1] Giu H, Yang H, Shen S, et al. Image-guided surgical navigation for removal of foreign bodies in the deep maxillofacial region. J Oral Maxillofac Surg 2013;71:1563–71. [2] Veselco M, Trobec R. Intraoperative localization of retained metallic fragments in missile wounds. J Trauma 2000;49:1052. [3] Öztürk AZ, İbrahim A. Late diagnosed nasal foreign body. Tr J Emerg Med 2005;5:86–8. [4] Kadish HA, Corneli HM. Removel of nasal foreign bodies in the pediatric population. Am J Emerg Med 1997;15:54–6. [5] Dolderer JH, Kelly JL, Morrison WA, et al. Foreign-body retrieval using a rare earth magnet. Plast Reconstr Surg 2004;113:1869–70. [6] Blankenship RB, Baker T. Imaging modalities in wounds and superficial skin infections. Emerg Med Clin North Am 2007;25:223–34. [7] Çakır B, Akan M, Yıldırım S, et al. Localization and removal of ferromagnetic foreign bodies by magnet. Ann Plast Surg 2002;49:541–4.
Please cite this article as: Sarıhan A, Can Ç, A case series featuring soft tissue foreign body removal with magnet in ED settings, Am J Emerg Med (2014), http://dx.doi.org/10.1016/j.ajem.2014.02.009
