Stereotactic Method to Isolate and Remove Foreign Bodies A
Simple
Stephan Ariyan,
MD
\s=b\ For the past several years, a simple technique using an image intensifier has been employed to isolate and remove foreign bodies from the extremities. Five consecutive cases were recorded to demonstrate its accuracy and simplicity. After the foreign body was identified by an x-ray film, the wound was infiltrated with local anesthesia and the foreign body was "located" by two venipuncture needles placed with the aid of an image intensifier. A small incision was then made between the needles to locate the foreign body at their tips. In this manner, foreign bodies have been consistently removed successfully in the emergency room in a relatively short period of time. (Arch Surg 112:857-859, 1977)
bodies in the extremities are challenging, for their localization by routine roentgenograms is usually difficult and misleading and their removal is often very frustrating. Several maneuvers and techniques have been devised to help locate these foreign bodies. One of these employed the application of the radiopaque letter 0, placed on the entrance wound before two views of the extremity were taken.1 The author of that technique advised making an accurate sketch outline on paper placed on the original roentgenogram, from which the measurements of depth could be taken and the surgeon could be guided to the foreign body. A useful suggestion has been the placement of two fine venipuncture needles at right angles, pointing towards the foreign body; obtaining several biplanar soft tissue roentgenograms; and repeating these until the image of at least one of these needles is superimposed on the foreign body.- Although helpful, the two-dimensional nature of the roentgenograms results in the frequent use of multiple roentgenograms and the dislodgement of the isolating needle while the patient is being transported back to the emergency room.
Foreign
Accepted
for publication Feb 8, 1977. From the Section of Plastic and Reconstructive Surgery, Yale University School of Medicine, New Haven, Conn. Read in part before the Resident Papers session of the Connecticut Chapter of the American College of Surgeons, Dec 3, 1975. Reprint requests to Section of Plastic and Reconstructive Surgery, Yale University School of Medicine, 333 Cedar St, New Haven, CT 06510 (Dr
Ariyan).
complicated but accurate technique has been reported using a Todd-Wells stereotactic headholder, often A
more
used in neurosurgery.1 The head or limb is immobilized in this exceedingly complex system by tongs or sterilized aluminum splints, a probe is inserted, and several selfdeveloping x-ray films are taken to localize the foreign body, which may then be removed. This technique has been used to remove foreign bodies from the soft tissues of the buccal area in proximity to the facial nerves, as well as to remove foreign bodies from the extremities with a modifi¬ cation of the headholder.4 All this, again, must be done in the operating room, and requires much skill in the use of the device. For the past several years, a simple technique has been employed to locate foreign bodies using the image inten¬ sifier in the x-ray department immediately adjacent to the emergency room. For the purposes of this presentation, five consecutive cases were documented with photography and timing to demonstrate the simplicity and accuracy of the technique. TECHNIQUE When a roentgenogram demonstrates the presence of a foreign body, the site of the wound is infiltrated with a local anesthetic in the emergency room before the patient is transported to the x-ray department. There, the patient is properly protected circumferentially around the trunk with lead aprons (as the x-ray beam is directed from beneath the table). The extremity is then prepared and draped for the procedure under aseptic control and two 19gauge venipuncture needles are placed from opposite directions, guided by intermittent exposure with the image intensifier, to pinpoint the radiopaque foreign body. The three-dimensional stereoscopic effect is obtained by asking the patient to move the extremity on command while the surgeon views the television screen of the image intensifier. The x-ray beam is shut off for each manipulation of the localizing needle for a new position, so that there is no radiation exposure to the hands of the surgeon. Once the foreign body is pinpointed between the two localizing needles, a small incision is made and the foreign body is located and removed. Although the incision made in Fig 1 is along a plane made by the two needles, we have subsequently found that an incision made between the needles keeps the needles more stable and the foreign body is easier to find at the tips of these needles.
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Fig 1.—Top left, Two guiding 19-gauge venipuncture needles for Top right, Roentgenograms from image intensifier demonstrating isolated foreign body. Bottom left, Incision between guiding needles and removal of foreign body. isolation.
Fig 2.—Isolation
of
foreign body
in
palm with guiding needles.
Fig 3.—Isolation of foreign body in foot with guiding radiopacity of piece of glass.
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needles. Note
Cost of Removal of Foreign Bodies Cost, $
Hospital: Inpatient Emergency room Hospital room Operating room Anesthesiology Recovery room Image intensifier Total
Emergency Room: Outpatient 40
113 ...
191 87 52 16 443 ...
56
RESULTS
There were two females and three males in this series, with an average age of 11 years (range, 6 to 30). Even young children have been found to cooperate in having foreign bodies removed in this manner if the operative site is properly anesthetized and the procedure is explained to them. The median duration from injury to removal of the foreign body was 24 hours, with a range of from 2>/2 hours to eight months. The median time taken to isolate the foreign body was two minutes (range, two to six) from first inserting the isolating needles. Median time taken for removal was IV2 minutes (range, 15 seconds to five minutes). The wounds are usually 2 to 3 cm in size, can be closed with three to four sutures, and the patients may be sent home after the procedure. The total time from the application of the needles to the removal of the foreign bodies was a median of four minutes. Failure to visualize the foreign body in a short period of time should be an indication to proceed to the operating room to explore the wound under tourniquet control. A case in point was the child who fell in school on his ball-point pen, the tip of which broke off and was imbedded in the thenar eminence of his dominant right hand. He was taken to a local physician, and with the patient under local anesthesia, attempts to remove the ball-point tip were unsuccessful. The child was then referred to us (Fig 2). Under the image intensifier, the ball-point tip was isolated with the needles within two minutes. However, after the incision was made, it was difficult to visualize the foreign body because of edema and contusion from the previous exploration; it was not safe to continue because of the proximity of this foreign body to the motor branch of the median nerve. The child was then taken to the operat¬ ing room and, under tourniquet control, the ball-point tip was isolated and removed through the same incision. Most patients had reported to the emergency room within a few hours after the puncture wound. However, some reported only when the foreign body caused symp¬ toms, which accounted for the delay from time of injury to removal. The longest interval was eight months, in a patient with a small piece of glass in his foot. He had come to the emergency room on three previous occasions, and surgical exploration after needle isolation with plain x-ray films alone had been unsuccessful each time. He returned the final time because he had a friend who had a foreign body removed by the present technique.
COMMENT There is a popular belief that glass is not radiopaque unless it contains lead. Although this concept has been published in textbooks from edition to edition, almost all glass in common use is, in fact, radiopaque. Radiopacity depends on density, and any two adjacent structures of different density will give a shadow in the soft tissue. The density of water is 1.0 and the average density of tissue, which is about 60% water, is 1.5. Since common glass has a density of 2.4 to 2.8, it is dense enough to impart a greater opacity than the tissue in which it is imbedded. Roberts3 demonstrated that the appearance of different types of glass (Plexiglass, Slideglass, Pyrex, window glass 1 to 2 mm thick) on roentgenographic film was better when exposed by standard techniques, as compared to exposure by soft tissue techniques. He further showed that a roentgenogram of these same samples of glass imbedded in a 4-cm piece of steak can be visualized, and that its radiologie visibility is not dependent on its lead content, but on its relative density. Therefore, in the patient with the piece of glass in his foot, we did, in fact, visualize, isolate, and remove the 3-mm piece of glass (Fig 3). Wayne and Carnazzo" have reported on the use of a fluoroscope for the removal of foreign bodies in a manner different than reported here. We do not agree with their under direct vision using an image suggestion that intensifier, the tip of a curved hemostat is introduced into the wound and guided to the foreign body." For one thing, any hemostat that is long enough to protect the surgeon from the x-ray beam cannot be manipulated for fine positional changes. For another, any blind placement of a hemostat into a wound to remove a foreign body may cause more harm than the foreign body would, if left in place. In comparison, the cost of the removal of a foreign body in the hospital in an operating room is far greater than the cost of the removal in the emergency room with an image intensifier (Table). However, it must be stressed that the image intensifier is used only as an aid to locate and pinpoint the foreign body by stereotactic principles, but in a more simple fashion. The foreign body is isolated without a series of roentgenograms, although a roentgenogram may be taken to document the isolation of the foreign body. The surgeon's hands are not exposed to radiation, as the machine is turned off during the relocation of the isolating needles. The foreign bodies may be isolated in a very short period of time. Nevertheless, the same surgical principles must be used in removing these foreign bodies at all times—they must be done under direct vision with knowledge and protection of adjacent structures. "
.
.
..
References 1. Meyer GW: Metallic foreign bodies in the sole of the foot. Ohio State Med J 65:906-907, 1969. 2. Touloukian RJ, Krizek TJ: Puncture wounds, in Diagnosis and Management of Trauma Emergencies. Springfield, Ill, Charles C. Thomas, 1974, pp 30-31. 3. Horton CE, McFadden JT: Stereotactic localization of a facial foreign body: Case report. Plast Reconstr Surg 47:598-599, 1971. 4. McFadden JT: Stereotactic pinpointing of foreign bodies in the limbs. Ann Surg 75:81-85, 1972. 5. Roberts WC: Radiographic characteristics of glass. Arch Indust Health 18:470-472, 1958. 6. Wayne R, Carnazzo AJ: Needle in the foot. Am J Surg 129:599, 1975.
Downloaded From: http://archsurg.jamanetwork.com/ by a University of California - San Diego User on 06/02/2015
Simple
Stephan Ariyan,
MD
\s=b\ For the past several years, a simple technique using an image intensifier has been employed to isolate and remove foreign bodies from the extremities. Five consecutive cases were recorded to demonstrate its accuracy and simplicity. After the foreign body was identified by an x-ray film, the wound was infiltrated with local anesthesia and the foreign body was "located" by two venipuncture needles placed with the aid of an image intensifier. A small incision was then made between the needles to locate the foreign body at their tips. In this manner, foreign bodies have been consistently removed successfully in the emergency room in a relatively short period of time. (Arch Surg 112:857-859, 1977)
bodies in the extremities are challenging, for their localization by routine roentgenograms is usually difficult and misleading and their removal is often very frustrating. Several maneuvers and techniques have been devised to help locate these foreign bodies. One of these employed the application of the radiopaque letter 0, placed on the entrance wound before two views of the extremity were taken.1 The author of that technique advised making an accurate sketch outline on paper placed on the original roentgenogram, from which the measurements of depth could be taken and the surgeon could be guided to the foreign body. A useful suggestion has been the placement of two fine venipuncture needles at right angles, pointing towards the foreign body; obtaining several biplanar soft tissue roentgenograms; and repeating these until the image of at least one of these needles is superimposed on the foreign body.- Although helpful, the two-dimensional nature of the roentgenograms results in the frequent use of multiple roentgenograms and the dislodgement of the isolating needle while the patient is being transported back to the emergency room.
Foreign
Accepted
for publication Feb 8, 1977. From the Section of Plastic and Reconstructive Surgery, Yale University School of Medicine, New Haven, Conn. Read in part before the Resident Papers session of the Connecticut Chapter of the American College of Surgeons, Dec 3, 1975. Reprint requests to Section of Plastic and Reconstructive Surgery, Yale University School of Medicine, 333 Cedar St, New Haven, CT 06510 (Dr
Ariyan).
complicated but accurate technique has been reported using a Todd-Wells stereotactic headholder, often A
more
used in neurosurgery.1 The head or limb is immobilized in this exceedingly complex system by tongs or sterilized aluminum splints, a probe is inserted, and several selfdeveloping x-ray films are taken to localize the foreign body, which may then be removed. This technique has been used to remove foreign bodies from the soft tissues of the buccal area in proximity to the facial nerves, as well as to remove foreign bodies from the extremities with a modifi¬ cation of the headholder.4 All this, again, must be done in the operating room, and requires much skill in the use of the device. For the past several years, a simple technique has been employed to locate foreign bodies using the image inten¬ sifier in the x-ray department immediately adjacent to the emergency room. For the purposes of this presentation, five consecutive cases were documented with photography and timing to demonstrate the simplicity and accuracy of the technique. TECHNIQUE When a roentgenogram demonstrates the presence of a foreign body, the site of the wound is infiltrated with a local anesthetic in the emergency room before the patient is transported to the x-ray department. There, the patient is properly protected circumferentially around the trunk with lead aprons (as the x-ray beam is directed from beneath the table). The extremity is then prepared and draped for the procedure under aseptic control and two 19gauge venipuncture needles are placed from opposite directions, guided by intermittent exposure with the image intensifier, to pinpoint the radiopaque foreign body. The three-dimensional stereoscopic effect is obtained by asking the patient to move the extremity on command while the surgeon views the television screen of the image intensifier. The x-ray beam is shut off for each manipulation of the localizing needle for a new position, so that there is no radiation exposure to the hands of the surgeon. Once the foreign body is pinpointed between the two localizing needles, a small incision is made and the foreign body is located and removed. Although the incision made in Fig 1 is along a plane made by the two needles, we have subsequently found that an incision made between the needles keeps the needles more stable and the foreign body is easier to find at the tips of these needles.
Downloaded From: http://archsurg.jamanetwork.com/ by a University of California - San Diego User on 06/02/2015
Fig 1.—Top left, Two guiding 19-gauge venipuncture needles for Top right, Roentgenograms from image intensifier demonstrating isolated foreign body. Bottom left, Incision between guiding needles and removal of foreign body. isolation.
Fig 2.—Isolation
of
foreign body
in
palm with guiding needles.
Fig 3.—Isolation of foreign body in foot with guiding radiopacity of piece of glass.
Downloaded From: http://archsurg.jamanetwork.com/ by a University of California - San Diego User on 06/02/2015
needles. Note
Cost of Removal of Foreign Bodies Cost, $
Hospital: Inpatient Emergency room Hospital room Operating room Anesthesiology Recovery room Image intensifier Total
Emergency Room: Outpatient 40
113 ...
191 87 52 16 443 ...
56
RESULTS
There were two females and three males in this series, with an average age of 11 years (range, 6 to 30). Even young children have been found to cooperate in having foreign bodies removed in this manner if the operative site is properly anesthetized and the procedure is explained to them. The median duration from injury to removal of the foreign body was 24 hours, with a range of from 2>/2 hours to eight months. The median time taken to isolate the foreign body was two minutes (range, two to six) from first inserting the isolating needles. Median time taken for removal was IV2 minutes (range, 15 seconds to five minutes). The wounds are usually 2 to 3 cm in size, can be closed with three to four sutures, and the patients may be sent home after the procedure. The total time from the application of the needles to the removal of the foreign bodies was a median of four minutes. Failure to visualize the foreign body in a short period of time should be an indication to proceed to the operating room to explore the wound under tourniquet control. A case in point was the child who fell in school on his ball-point pen, the tip of which broke off and was imbedded in the thenar eminence of his dominant right hand. He was taken to a local physician, and with the patient under local anesthesia, attempts to remove the ball-point tip were unsuccessful. The child was then referred to us (Fig 2). Under the image intensifier, the ball-point tip was isolated with the needles within two minutes. However, after the incision was made, it was difficult to visualize the foreign body because of edema and contusion from the previous exploration; it was not safe to continue because of the proximity of this foreign body to the motor branch of the median nerve. The child was then taken to the operat¬ ing room and, under tourniquet control, the ball-point tip was isolated and removed through the same incision. Most patients had reported to the emergency room within a few hours after the puncture wound. However, some reported only when the foreign body caused symp¬ toms, which accounted for the delay from time of injury to removal. The longest interval was eight months, in a patient with a small piece of glass in his foot. He had come to the emergency room on three previous occasions, and surgical exploration after needle isolation with plain x-ray films alone had been unsuccessful each time. He returned the final time because he had a friend who had a foreign body removed by the present technique.
COMMENT There is a popular belief that glass is not radiopaque unless it contains lead. Although this concept has been published in textbooks from edition to edition, almost all glass in common use is, in fact, radiopaque. Radiopacity depends on density, and any two adjacent structures of different density will give a shadow in the soft tissue. The density of water is 1.0 and the average density of tissue, which is about 60% water, is 1.5. Since common glass has a density of 2.4 to 2.8, it is dense enough to impart a greater opacity than the tissue in which it is imbedded. Roberts3 demonstrated that the appearance of different types of glass (Plexiglass, Slideglass, Pyrex, window glass 1 to 2 mm thick) on roentgenographic film was better when exposed by standard techniques, as compared to exposure by soft tissue techniques. He further showed that a roentgenogram of these same samples of glass imbedded in a 4-cm piece of steak can be visualized, and that its radiologie visibility is not dependent on its lead content, but on its relative density. Therefore, in the patient with the piece of glass in his foot, we did, in fact, visualize, isolate, and remove the 3-mm piece of glass (Fig 3). Wayne and Carnazzo" have reported on the use of a fluoroscope for the removal of foreign bodies in a manner different than reported here. We do not agree with their under direct vision using an image suggestion that intensifier, the tip of a curved hemostat is introduced into the wound and guided to the foreign body." For one thing, any hemostat that is long enough to protect the surgeon from the x-ray beam cannot be manipulated for fine positional changes. For another, any blind placement of a hemostat into a wound to remove a foreign body may cause more harm than the foreign body would, if left in place. In comparison, the cost of the removal of a foreign body in the hospital in an operating room is far greater than the cost of the removal in the emergency room with an image intensifier (Table). However, it must be stressed that the image intensifier is used only as an aid to locate and pinpoint the foreign body by stereotactic principles, but in a more simple fashion. The foreign body is isolated without a series of roentgenograms, although a roentgenogram may be taken to document the isolation of the foreign body. The surgeon's hands are not exposed to radiation, as the machine is turned off during the relocation of the isolating needles. The foreign bodies may be isolated in a very short period of time. Nevertheless, the same surgical principles must be used in removing these foreign bodies at all times—they must be done under direct vision with knowledge and protection of adjacent structures. "
.
.
..
References 1. Meyer GW: Metallic foreign bodies in the sole of the foot. Ohio State Med J 65:906-907, 1969. 2. Touloukian RJ, Krizek TJ: Puncture wounds, in Diagnosis and Management of Trauma Emergencies. Springfield, Ill, Charles C. Thomas, 1974, pp 30-31. 3. Horton CE, McFadden JT: Stereotactic localization of a facial foreign body: Case report. Plast Reconstr Surg 47:598-599, 1971. 4. McFadden JT: Stereotactic pinpointing of foreign bodies in the limbs. Ann Surg 75:81-85, 1972. 5. Roberts WC: Radiographic characteristics of glass. Arch Indust Health 18:470-472, 1958. 6. Wayne R, Carnazzo AJ: Needle in the foot. Am J Surg 129:599, 1975.
Downloaded From: http://archsurg.jamanetwork.com/ by a University of California - San Diego User on 06/02/2015
