Lower extremity puncture wound.

Abstract

A 58-year-old woman presented with pain after sustaining a right foot wound from a damaged wooden floor. Physical examination was remarkable for a 0.3-cm puncture wound between the first webspace on the plantar aspect of the foot with tenderness to palpation, but no visible or palpable foreign body. Plain radiographs were negative, and computed tomography of the foot noted the small puncture wound with a proximally extending linear tract. Orthopedic surgery was consulted but did not appreciate any foreign body and thus recommended conservative management without wound exploration in the emergency department (ED). Bedside ultrasound was then performed by emergency physicians that visualized a linear 4-cm hyperechoic foreign body with posterior acoustic shadowing (Figure 1, Video 1). Ultrasound-guided deep peroneal and posterior tibial nerve blocks were performed for anesthesia (Video 2). Under ultrasound guidance, curved forceps were used to grasp and remove a large wooden fragment (Figure 2, Video 3). The patient was discharged with oral antibiotics. Traumatic wounds are responsible for 11 million ED visits annually, and foreign bodies are involved in 7% to 15%.1 Many foreign bodies are missed on initial evaluation, and because of their risk for complications, they are frequently implicated in malpractice litigation.2 Plain film radiographs are considered first line and detect 80% of all foreign bodies but have a mere sensitivity of 15% for radiolucent objects, such as wood or other vegetative material.1, 3 Therefore, multimodal imaging is frequently necessary. Ultrasonography, performed in the ED setting, has an overall sensitivity and specificity of 91% for identifying foreign bodies.2 These will appear hyperechoic and may have additional clues, such as posterior acoustic shadowing, reverberation artifact, or hypoechoic halo. Using ultrasound to guide percutaneous foreign body removal can increase success in the ED to nearly 100%.4 Please note: The publisher is not responsible for the content or functionality of any supporting information supplied by the authors. Any queries (other than missing content) should be directed to the corresponding author for the article.