Indicated only if location of foreign body (FB) is certain

 Removal may be done in 30 minutes or less

RELATIVE CONTRAINDICATIONS

 Involvement of joint—orthopedic consultation may be required

 Coagulopathies or bleeding diathesis

 Allergy to anesthetic

 Chronic medical problems that delay healing, such as diabetes, uremia, or immunocompromised state

 Involvement of abdomen/pelvis/thorax

 Near major vascular structures that are difficult to visualize

 Uncooperative, difficult, or intoxicated patient

 FB not localized

RISKS/CONSENT ISSUES

 Procedure can cause pain (local anesthesia will be given)

 Local bleeding

 There is potential for introducing infection (sterile technique will be utilized)

 Risk of injuring local neurovascular structures

 Scar at site of FB removal

 Patient must be informed that all FBs may not be removed

 Retained wood FBs always develop an inflammatory response, but retained bullets rarely produce inflammation

TECHNIQUE

 Localize the FB

    Get multiple projections of plain x-ray using a soft-tissue technique (e.g., underpenetrated film); to locate radiopaque FBs, place a marker (i.e., needle) on the skin surface at the wound entrance before the x-ray procedure

    Although glass and metal are easily located with plain films, ultrasonographic localization may be required for wood and thorns

    All intraorbital and intracranial FBs must be imaged by computed tomography (CT)

    If a patient has a previously explored wound demonstrating signs of infection, poor wound healing, or persistent pain, consider doing a CT

 Patient Preparation

    Sterilize and drape the area from where FB will be removed

    Anesthetize area either via local infiltration or appropriate nerve block

 General Removal Techniques

    Enlarge the entrance to wound with an adequate skin incision

    Spread the soft tissue with hemostats, avoiding use of fingers

       Hemostats can help find glass in a wound by creating a clicking sound when tapped against glass

    If visualization is inadequate, consider excision of small block of tissue, only if no significant neurovascular structures are involved

    When searching for a thorn or needle, consider an elliptical incision, undermine the skin in all directions, and then compress the sides, expelling the FB

    Closure of the wound after thorough irrigation is indicated unless exploring a contaminated wound

TICK REMOVAL

 Nonmechanical means of tick removal is not recommended (i.e., drowning the tick in petroleum jelly), because it may cause the tick to regurgitate, increasing infection risk (FIGURE 84.1)

 Mechanical removal

    Using the tip of forceps, grab the tick as close as possible to the patient’s skin, and apply steady traction

    Ensure that all mouth parts are removed. Use an 18-gauge needle to remove retained pieces.

    Thoroughly cleanse the area with soap and water

 In patients at high risk of Lyme disease, consider administration of 200 mg of doxycycline in a single dose (or amoxicillin in pediatrics) (Figure 84.1)

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