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Clinical Case 101: Going Glass Hunting

Broome is a fun place – it is always warm, the locals are nearly pathologically “laid back”.  Shoes are worn by fewer than 50 % of the populace!  This creates a few common ED scenarios.  Foot infections and injuries are common – especially the “glass foreign body in foot” scenario.

Now – I remember when I was an intern working in ED and I spent an hour digging, probing and ‘excising’ a never-seen glass FB from a chap’s foot.  It was torture – he felt it all and I simply did not know better.  However, I still see the ever-frustrating “glass hunting” on a regular basis happening in my ED.

So I thought I would share a case – to show how I roll now when chasing FBs in feet.

Here is the case.  Nice young lady with no medical problems – she was at a party and trod on some glass from a broken bottle 3 days ago.  No shoes, as is the norm.

She slept and awoke with a sore foot – she can feel pain on every step over the heel.  There wis a small skin puncture – and she has had a go at probing it with a sewing needle [which she ‘sterilised’ with a cigarette lighter].  But – no luck – she is still limping on the ball of her foot.  No apparent infection.

So how would you approach this?  Any imaging?  Or just have a probe?  Would you attempt to anaesthetise the area?

Well I have seen a lot of techniques over the years – and this is how I play it in 2014.

(1)  Always image.  Ultrasound is great for small FBs – but there are a few tricks that you need to be aware of.

  • High frequency probe, dialled up to the shallowest depth it will do.
  • Turn OFF the multi beam / image-enhancing / optimisation software – these will make it harder to see the shadow artefact that you are looking for.
  • Here’s a previous post where I discuss why this is important.
  • Use a heap of gell to get a “Stand- off” between the skin and the probe – also fills in any skin cracks / breaks that might spoil the delicate high freq image
  • Or put the foot in a bath of water to allow completely excellent transfer of sound waves.

You could get a plain film XR if the US isn’t working – problem is that it does still make it tough to decide exactly where that little shard of glass is in the skin.  And the next few steps use US anyway!

(2) If you see a FB – great! Move to step (3).  IF you cannot see a FB despite your best image effort – then you need to seriously consider stopping at this point.  It may be that there is NO FB! That the patient is just feeling pain from a clean cut that has no FB or a trivial speck of dirt within.   In my opinion this should  not be explored.  It will declare itself  if you are missing something too small to see on US.

(3)  OK so there is a FB – cool.  Now you need to orientate the lie of the FB.  Get the angle, the depth, the direction all clear in your head – because once you start digging – it can be tough to say where and what you are doing.

(4)  Before you start digging – do a nice simple posterior tibial nerve block.  It is easy.  You could do it blind – but you have the probe right there and there is some evidence to suggest that US-guided blocks of this nerve work better than the “landmark” blocks.

  • If you want to know how: check out the Sonoguide site here
  • If you want to see why I think you should do it under US-guidance – see this paper from Redborg et al
  • If you are still not convinced – then listen 
    My wife and I were serious mountain trekkers before kids!One year we were training hard for a tour around Nepal when she developed plantar fasciitis – overdoing the new boots! So being a young, keen anaesthetic Reg – I volunteered to do a steroid injection – under a posterior tibial block. It seemed humane, and would mean we were ready for the Annapurna circuit next week! But I did not have and US in our bathroom as I did the block! And I managed to skewer the nerve directly with my block! Ouch – direct hit and neuronal injury. I proceeded to do the steroid injection (pain free) but she was left with a numb sole…. until a week later when she developed a painful shooting dysaesthesia into her foot with every step! So off we went to beautiful Nepal….. and it was a long road, with plenty of pain and guilt… So take my word for it – use the US to avoid intraneural injection or nerve injury

(5)  Put in the block and then go and see the next patient.  These blocks take 10 – 20 minutes to get to best effect.  So take your time and your patient will feel less pain.

(6)  Now there are a few techniques for getting the glass out.

  • If you can see it / grab it  with a small nick in the skin – great.  However, this is usually not the case.
  • You can use the US to slide a small needle under the FB – so you have a guide.  Then just cut down onto the needle shaft and it should pop into view.  Here is a paper from Kenechi Nwawka and colleagues in Journ of Foot & Ankle Surg, 2014 describing this in a few nice cases
  • If there is already a mess of skin from previous attempts – I am not too proud to simply excise a small ellipse of skin and core of sub cut tissue  – FB included.  You can then just close it with a few stitches.

The really sexy part of this is step (7)

(7)  Now get your probe and rescan the patient’s foot.   The FB should be gone.  Or you can put the it of skin into a bath and scan it – and the same FB you saw before should now be in the specimen!  Magic – patient’s love seeing this bit.

(8)  Never perform surgical procedures on your wife at home.  Even on a good day this will lead to pain and suffering.  It is just not cool. Do not do it!

Comments

  1. Casey, interesting post. I’ve been asking around about this and find some variation on management here. I haven’t reviewed the lit but would be interested to see what’s out there. Here are the ideas I’ve gotten on this

    Small FB
    1 – flush the wound as much as possible to try and get it out. Re-XR and if still retained (or even if the area looks clear of debris) tell the patient there may still be an FB in it and they’ll have to follow up with a specialist regardless. Close the wound and no antibiotics (if minimal comorbidities)
    2 – flush the wound and re-XR. If still retained, leave it open or loosely approximate with steris or sutures and arrange f/u in 24 hours (or consult in ED if possible and you prefer). Antibiotics whether you leave it open or close if you think there’s retained FB.

    Large FB – more agreement here. Flush out the wound, attempt to remove FB and re-XR when you think you have. If you got it out, close and send for f/u +/- abx. If the XR still shows FB, leave it open, cover with abx and either get consult in ED or arrange 24 hour follow up.

    Only one of the people I asked would core out the area.

    In the states, this is a big area of litigation. Either retained FB that wasn’t known about or chronic pain/loss of function from an FB. Also, I work in a tertiary referral center so easy to say that I would consult or get follow up at 24 hours.

    Thanks again for the post and let me know if you find any lit on the topic.

  2. Muhammad "Umer" Shehzad says:

    A common scenario indeed.
    Here are my submissions:

    1) If the patient say they have a foreign body (FB), they have a FB, even if the Xray does not show it. Glass has lead in it, and that is what makes it visible on an Xray. It means that the glass FB may or may not be visible depending on the lead content in it.

    2)Always Xray the soft tissues for foreign bodies, especially glass. Most glass is visible rather than not visible on Xrays.

    3)THE MOST IMPORTANT THING:
    One must have the RIGHT TOOL. We go hunting for Foreign Bodies (FBs) with normal forceps. That is the best way to NOT find the FB and drive it deeper or further. There is a reason they invented the “HUNTER SPLINTER FORCEPS”.
    With this, after mapping the anatomy of the FB, its a breeze to dig it out. It has a diamond-shaped expanded tip which is angled.Highly recommended. You can have a look at this Curved/angled Hunter splinter forceps (there is a straight variety too).

    http://www.americanmedicals.com/hunter-splinter-forceps-curved.html

  3. David Berger says:

    Great post, Casey. Thanks a lot!

  4. Hi Casey, great advice for a common problem.

    Also known as nightclub foot in Virchester when young (mostly ladies) folks take their shoes off in nightclubs after dancing until they are sore. Walking around barefoot in a nightclub is not wise, and with the addition of alcohol the subsequent glass FB may not be noticed until the next day.

    The USS guided block is an absolute game changer for me 🙂 , but all of this is gold advice.

    S

  5. Great post Casey…..US and US nerve blocks can be Great Problem solvers in every Critical care setting!!!!!

  6. Ron Cassano says:

    As usual Casey a great blog , and I haven’t anything extra to add, it’s the perfect procedure; 1 thought : if you don’t have US available use your clinical examination and history , get clear the likely direction of entry , use LA to infuse under the suspected FB, which will likely lift it under the created bleb, and make a big enough incision to properly explore; this works 90% of the time but there’s no proof of FB or it’s extraction unless you remove it! And remember there could be more than 1 FB in there, esp with glass and splinters that have been walked on.

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