Localization, detection and guided removal of soft tissue in the hands using sonography

Ultrasound with needle guiding exploration as a real-time modality for exploration of air rifle bullet close to cervical spine: A case report

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Real-time imaging modalities are needed while performing surgical exploration of retained foreign body.

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Ultrasonography offered an ability to visualize retained foreign body in a real-time.

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Needle guiding ultrasonography is a technique that allows surgeon to extracts the retained foreign body precisely.

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The combination of a needle guided ultrasonography, and other imaging studies may increase the accuracy of exploration.

Introduction and importance

Surgical exploration of retained air rifle bullet at the neck region is challenging because it is difficult to find bullets during exploration and prevent damage to vital structures. A bedside real-time imaging technique is needed to determine the retained bullet's location to the surrounding structures and guiding exploration.

Case presentation

A 19-year-old male patient was admitted to the emergency department with neck pain after being shot by an air rifle. The patient's vital signs were stable. A small entry wound to the right lateral side of the neck without exit wound was found without neurological symptoms. The cervical X-ray showed the bullet at the third cervical vertebrae level. Surgical exploration was performed with needle-guiding ultrasonography. The bullet is a one-centimeter anterior transverse process of the third cervical vertebra marked by a hyperechoic object. Exploration was done by tracing the needle. Postoperative neurological evaluation was conducted, and no abnormalities were found.

Clinical discussion

Preoperative imaging modalities are crucial before the surgical exploration of a retained air rifle bullet. X-ray and CT-scan are imaging modalities that are often used as an initial assessment of retained foreign bodies. However, ultrasonography provides advantages over X-ray and CT scan to provide real-time imaging that supports the surgeon while performing surgical exploration. Ultrasonography with needle guiding exploration increases the precise location of a retained air rifle bullet.

Conclusion

Ultrasonography was a simple and precise real-time imaging modality for identifying and guiding the exploration of a retained air rifle bullet in the neck area.

Relevance of intraoperative ultrasound imaging for detecting foreign bodies in the hand: A series of 19 cases

Radiolucent foreign bodies of the hand are frequent and may lead to pain, infection, hematoma and/or migration. Their diagnosis and removal can be difficult. The goal of this study was to assess the usefulness of intraoperative ultrasound imaging for detecting translucent foreign bodies in the hand to facilitate their removal. Our single-center retrospective study included 19 patients with preoperatively radiolucent but echogenic foreign bodies. An intraoperative ultrasound was performed to assist with and confirm the removal of the foreign body. The foreign bodies were vegetal in 15 cases, made of glass in 2 cases, rock in 1 case and undetermined in 1 case. The average length was 4.65 mm (min 1, max 16) and the average width 1.02 mm. All foreign bodies were visible during the intraoperative ultrasound and were no longer visible after their removal. Because intraoperative ultrasound imaging was able to guide the removal of all radiolucent foreign bodies in our study, it can be a useful tool for the removal of radiolucent foreign bodies.

Ultrasound-Guided Removal of an Infected Loose Body from the Quadriceps Muscle

We present the case of a 35 year-old male with pain and swelling in his right thigh. By CT and sonography, an abscess was localized to the deep, anteromedial, mid-thigh within the quadriceps muscle, along with a 1.3 cm loose body. The infected loose body was removed under ultrasound guidance without complications.

Ultrasound-guided intervention in the ankle and foot

In this comprehensive review, we discuss the main interventions performed in the foot and ankle for Achilles tendinopathy, Morton's neuromas and Plantar fasciitis as well as techniques for intra-articular and peritendinous injections. We present the different imaging techniques and injectable agents that can be used in clinical practice, trying to help the reader decide the most appropriate way of managing the patient with a problem in the ankle and foot.

Diagnostic Accuracy of Ultrasonography in Retained Soft Tissue Foreign Bodies: A Systematic Review and Meta-analysis

OBJECTIVES

Open wounds with the potential for retained foreign bodies are frequently seen in the emergency department (ED). Common foreign bodies, such as wood or glass, are often missed on physical examination and conventional radiography. The increased use of ultrasonography (US) in the ED presents an opportunity to better identify retained soft tissue foreign bodies, and understanding of its test characteristics is desirable. The authors set out to determine the test characteristics of US for detection of soft tissue foreign bodies by performing a systematic review and meta-analysis of the existing literature.

METHODS

This was a thorough, systematic review of OVID Medline, SCOPUS, and Cochrane databases and a limited review of Directory of Open Access Journals, Google Scholar, and ClinicalTrials.gov to identify clinical studies examining the diagnostic accuracy of US in the identification of retained soft tissue foreign bodies. Studies were selected for full-text review by two independent reviewers to determine if they met inclusion criteria. Results were pooled for test characteristics using STATA and assessed for risk of bias and applicability using the QUADAS-2 tool.

RESULTS

This systematic search strategy identified 5,059 unique articles, and 17 articles met inclusion criteria. Pooled sensitivity and specificity were, respectively, 72% (95% confidence interval [CI] = 57% to 83%) and 92% (95% CI = 88% to 95%). Overall quality of the studies was low and interstudy heterogeneity was high (I(2)  = 90%, 95% CI = 80% to 100%).

CONCLUSIONS

Ultrasonography is highly specific and moderately sensitive in the identification of retained soft tissue foreign bodies; however, studies to date have a high degree of heterogeneity and a high risk of bias.

A simplified training method for soft tissue foreign body detection using ultrasound in emergency medicine residency program

Using ultrasound for detecting soft tissue foreign bodies seems to be the preferred choice with minimum invasion and easy availability at the bedside in emergency departments. In this study, a workshop (1 hour of lecture presentation and 3 hours of interactive hands-on) was designed to evaluate the efficacy of a short course of simple interactive training to improve the ability of emergency medicine residents to detect foreign bodies with ultrasound. Eight pieces of fresh full thickness (10 × 10 × 10 cm) lamb leg muscle were used in this study. Five different types of foreign bodies, including: a piece of glass (5 × 5 × 4 mm), wood (5 × 5 × 4 mm), gravel (5 mm diameter), plastic (5 × 5 × 2 mm) and a nail (25 mm in length) were placed deep inside each lamb leg. An ultrasound machine with a 7.5 MHz linear probe was used in this study. 35 emergency medicine residents (12 PGY1, 11 PGY2 and 12 PGY3) were enrolled in this study. Pretest and post-test results were compared and analyzed. Among all 35 participants in the training session, foreign body detection was significantly improved after the workshop (p < 0.001). Overall sensitivity and specificity for differentiating the presence and absence of a foreign body with 95% confidence were 60% (75% for PGY3) and 85.7% (91.7% for PGY3), respectively. The overall accuracy increased from 20.2% to 72.8% due to this session. This study supported the possibility of using ultrasound to detect foreign bodies by emergency physicians with a very short training course. This is highly beneficial for overcrowded emergency departments.

Canine tooth in hand - A rare entity

The hand plays an important role in day to day activities and is more prone for accidental injuries. Injuries to the hand are frequently associated with foreign body penetration. Many a times the foreign body is not detected at the initial visit and can later present with other complications. We present a case of canine tooth presenting as a retained foreign body in the hand following a dog bite. The article stresses the importance of looking for foreign bodies in penetrating hand injuries, even in wounds that seem to be minor in nature.

Sequelae of foreign bodies in the wrist and hand

BACKGROUND

Penetrating injuries to the hand are a common occurrence in the emergency room, and embedment of foreign bodies is suspected in many of these cases. The existing literature offers little information on retained foreign bodies. The aim of this study was to identify characteristics, determine prevalence, and observe outcomes for retained foreign bodies in the wrist and hand.

METHODS

Four hundred thirty-seven consecutive hand and wrist radiographs in 437 patients from the emergency department of a level 1 trauma center were reviewed for the presence of retained foreign bodies. Location, size, number, and type of foreign body were recorded. Patient demographics, mechanism of injury, associated injuries, and treatment were obtained from medical records. All subsequent hospital and outpatient encounters were reviewed. Follow-up period was 18 months (range, 1-40).

RESULTS

Of 437 cases, 65 patients (15 %) had at least one retained foreign body. Nineteen patients underwent removal of foreign body at initial presentation. The average size of foreign bodies removed was 6 mm, compared to 3 mm for those retained. Of 46 patients where the foreign body was left in situ, two (4 %) developed symptoms directly related to the retained foreign body. One of these patients underwent removal.

CONCLUSIONS

This study supports the safe removal of foreign bodies which are easily accessible or when part of a broader procedure to repair injured structures. Otherwise, we advocate expectant management for all other patients, as the likelihood of persistent symptoms is low and only 2 % of retained foreign bodies required removal later.

Ultrasonographically supported removal of foreign bodies of the eye lid and parapharyngeal space in a 13-year-old boy subjected to shot injuries in early childhood

Background: B-scan ultrasonography is widely used in diagnostics of head and neck pathologies. Ultrasonography can be applied intraoperatively to identify foreign materials.

Case report: This case report describes the ultrasonographic identification of foreign bodies of the eye lid and parapharyngeal space in an adolescent who was injured several years ago, obviously a victim of domestic violence. B-scan ultrasonography (small part transducer, emission frequency: 7.5 MHz) proved to be a reliable tool to locate the foreign bodies. Ultrasound imaging facilitated the decision-making of the surgical approach and thus reduced the surgical exploration time.

Discussion: B-scan ultrasonography is a valuable tool in oral and maxillofacial surgery. The use of B-scan ultrasonography in the head neck region requires the capacity of the surgeon to fuse the ultrasonographic picture with the topography of the head and neck. The advantages and limitations of B-scan ultrasonography in the head and neck region concerning foreign body identification are briefly discussed.

ULTRASOUND FOR THE DETECTION OF VEGETATIVE FOREIGN BODY IN HAND — A CASE REPORT

Foreign bodies in soft tissues are commonly encountered in daily orthopaedic practice. While most of the metals and glass foreign bodies can be detected by plain radiograph, organic substances such as wood and vegetative materials are radiolucent. Unfortunately, these radiolucent foreign bodies are usually more prone to cause an inflammatory reaction and infection. The detection can be even more difficult in cases of multiple foreign bodies and in penetrating injuries with small innocuous skin wounds. Ultrasonography is a sensitive and reliable investigation for detection of foreign bodies in soft tissue. We present a case of penetration injury to thumb with residual radiolucent foreign bodies and demonstrate the proper role of ultrasonography in the management of foreign bodies in soft tissues.

Ultrasound in the diagnosis of clinical orthopedics: The orthopedic stethoscope

Ultrasonography has advantages over other imaging modalities in terms of availability and comfort, safety, and diagnostic potential. Operating costs are low compared with both computed tomography (CT) and magnetic resonance imaging (MRI). The portable equipment is accessible at locations distant from medical centers. Importantly, ultrasonography is performed while patients lie in a comfortable position, without pain or claustrophobia. Ultrasonography is a totally safe noninvasive imaging technique. In contrast to CT and X-rays, it does not emit ionizing radiation. Unlike MRI, it is safe for all patients, including those with cardiac pacemakers and metal implants, without any contraindications. Of the many indications for musculoskeletal ultrasonography, the evaluation of soft tissue pathology is particularly common. In addition, ultrasonography is useful for the detection of fluid collection, and for visualization of cartilage and bone surfaces. Color or power Doppler provides important physiological information, including that relating to the vascular system. The capability of ultrasonography in delineating structures according to their echotextures results in excellent pictorial representation. This imaging principle is based on physical changes in composition, as compared to imaging with MRI, which is based on changes in chemical composition. This article reviews the contribution of sonography to the evaluation of the musculoskeletal system.

Missed foreign bodies in the hand: an experience from a center in Kashmir

Introduction

Penetrating hand injuries are common and improper assessment can result in missed foreign bodies. These bodies can result in a wide range of complications.

Aim

The aim of our study was to study the profile of patients reporting with missed foreign bodies in the hand.

Materials and methods

All the cases treated in the Department of Surgery, Sheri Kashmir Institute of Medical Sciences (medical college), Kashmir, for missed foreign bodies in hands from June 2003 to May 2009 were studied retrospectively.

Results

A total of 61 cases with missed foreign bodies of different nature were treated over the period of six years. Wooden splinters were the most common foreign bodies missed. Preoperative localization was accomplished with plain radiographs and ultrasonograms. Most of the cases were treated on outpatient basis.

Conclusions

Foreign bodies should be suspected and ruled out in all cases of penetrating injuries of hands. Missed foreign bodies need to be removed after proper localization by imaging.

Bedside pediatric emergency evaluation through ultrasonography

Bedside US has emerged as a valuable technology for the emergency department physician. It impacts clinical decision-making and the safety of procedures, and it decreases the time and increases the efficiency for completion of procedures. The portability, accuracy and noninvasive nature of US make it an ideal tool for the trained clinician. Bedside US can improve clinical decision-making for the pediatric patient by helping the clinician to identify critical pathology, direct therapeutic maneuvers and determine the futility of resuscitations. Many pediatric procedures, such as vascular access, lumbar puncture and bladder catheterization, are typically performed blindly. Bedside US enhances the success of procedures, minimizes complications and limits the number of attempts necessary to complete a procedure. Bedside US can be a valuable adjunct for complicated and time-sensitive disease processes such as ectopic pregnancy, testicular torsion and hypovolemia by providing information to guide diagnostic and therapeutic interventions that subsequently improve outcomes.

ULTRASONOGRAPHIC FEATURES OF GRASS AWN MIGRATION IN THE DOG

The aim of this study was to describe the ultrasonographic features of grass awns in soft tissue. A 10 MHz linear transducer was used. Ultrasound images from 25 dogs (27 awns) were collected and compared with the results from water bath studies using wild oat seeds (Avena spp.) collected in the field. Wild oat seeds were the most common grass awn found in soft tissue of dogs. Ultrasonographically grass awns appeared as a double/triple spindle-shaped echogenic interface within soft tissue. The same appearance was observed in water bath studies. In four dogs, the grass awn was removed surgically with a clamp introduced into a fistulous tract, using sonographic guidance. The grass awn was not found surgically in only three dogs, suggesting more attention during surgery. Ultrasonography is a useful diagnostic imaging technique to identify grass awns within soft tissue.

Large wooden foreign body in the hand: recognition of occult fragments with ultrasound

A 37-year-old man with pain and swelling of the thenar was referred to the emergency department. On ultrasound a 3 x 1 x 0.2 cm large wooden foreign body was depicted in the thenar region. In addition, ultrasonography (US) was able to show multiple smaller fragments adjacent to the larger foreign body. To give a better overview of the position relative to tendons and muscles, CT with soft tissue window settings was performed. CT gave a good anatomic overview but was not able to show the smaller fragments. A total of six additional fragments were depicted at US. Performing US is mandatory in patients with penetrating injuries by foreign bodies because it is very sensitive. Using US in an emergency setting can avoid retained fragments and depict other soft tissue complications.