Physical Examination

Physicians are occasionally surprised by foreign bodies that can be embedded in small or seemingly superficial wounds. 5 Several physical findings indicate the presence of a foreign body. A discoloration or visible mass under the epidermis makes the diagnosis obvious. Sometimes a mass cannot be seen but can be palpated. Sharp, well-localized pain with palpation over a puncture wound is a useful sign. Patients who report the sensation of "something in the wound" should be taken seriously because their perceptions are often correct. If passive range of motion of a joint near a wound is limited, a foreign body may be responsible.

Old wounds with retained foreign bodies may have a persistent purulent drainage, a chronic draining sinus, or a chronic granulomatous reaction. A sterile abscess that complicates wound healing may be the result of a foreign body.

Some foreign bodies are discovered in wounds unexpectedly, but most are found during a deliberate and careful exploration of wounds considered to be at risk. Adequate lighting, good hemostasis, complete local anesthesia, and patient cooperation are essential. Every effort should be made to visually inspect all recesses of a wound. Wounds deeper than 5 mm and wounds whose depth cannot be visualized have a higher association with foreign bodies. 5 If punctures and other narrow wounds make direct visualization difficult and the physician is concerned about the possibility of a foreign body below the surface, the wound margins should be extended with a scalpel (Fig 42-1). However, wounds that penetrate deeply into adipose tissue are difficult to explore and easily hide foreign material. Blind probing with a hemostat is a less effective but sometimes acceptable alternative to wound exploration when the wound is narrow and deep and extending the wound is not desirable. This method is used frequently to evaluate plantar puncture wounds caused by nails and to search for clear glass, which is difficult to see in a wound. A closed hemostat should be introduced into the wound and either used as a probe or spread open and then withdrawn. If an instrument strikes a metallic or glass foreign body, it will produce a grating sensation. The instrument should not be used to grasp blindly in hopes of clamping an unseen object. This technique is especially dangerous in hands, feet, or faces, where direct visualization is the preferred method of exploration.

FIG. 42-1. A. (Plate 1) This patient's leg was punctured by a wooden stake 2 days prior to presentation. Surrounding cellulitis and point tenderness lateral to the wound increased the probability of a retained foreign body. B. (PJate.2.) The entrance to the wound was extended. C. (Plate..3) A 15-cm piece of wood was removed from a 3.5-cm-deep wound.

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