ORIGINAL CONTRIBUTION
foreign body, diagnosis
Foreign Body Retention in Glass-Caused Wounds From the University of MissouriKansas City School of Medicine, Department of Emergency Medicine;* Truman Medical Center;t and the University of Missouri-Kansas City School of Pharmacy, t Kansas City, Missouri. Received for publication September 6, 1991. Revision received June 5, 1992. Accepted for publication June 14, 1992.
Julian B Montano, MD*
Study objective: Todescribe patient and wound characteristics
Mark T Steele, MD, FACEP*t
that are clinically useful in identifying wounds that were caused by glass and retained a foreign body.
William A Watson, PharmD, DABATr~
Design: Retrospective consecutive case review.
Setting: Urban, university-affiliated teaching hospital. Type of participants: Four hundred thirty consecutive patients with a total of 578 evaluable wounds caused by glass during a 12-month period. Measurements and results: Medical records were reviewed to
determine patient demographics, primary wound data (eg, location, type, description), mechanism of injury, type of glass involved, and presence of foreign body sensation. 61ass was found by examination in 7% of wounds. Eight percent of 137 radiographs were positive. Wounds with the highest prevalence of retained glass were puncture wounds (P< .0005), those caused by stepping on glass or by a motor vehicle accident (P< .005), and those of the head or foot (P< .003).
Conclusion: Characteristics of wounds most likely to retain glass were identified in this retrospective study. The presence of these factors should increase the clinician's suspicion of a retained glass foreign body. The indications for radiography for the detection of retained glass in wounds should be clarified with prospective studies. [Montano JB, Steele MT, Watson WA: Foreign body retention in glass-caused wounds. Ann EmergMedNovember 1992;21: 1360-1363.]
76/1360
ANNALS OF EMERGENCY MEDIOINE 21:11 NOVEMBER1092
FOREIGN B O D I E S
Montano, Steele & Watson
INTRODUCTION
RESULTS
GLass is a frequent cause of wounds in patients who present to the emergency department. Most wounds are thought to not have retained glass, but no data exist to verify this observation. It also is unknown whether routine clinical examination or wound exploration will identify retained glass pieces. Glass detection can be difficult in some wounds. 1-3 Residual material can r e s u l t in delayed wound healing, infection, and tissue damage; 3-a therefore, detection is important. Plain radiographs can help confirm the presence or absence of glass in cases where wound exploration is difficult.9,1° There are no clinical predictors for wounds at high risk for glass retention that can be used as an indication for radiographic studies. We conducted a retrospective study to describe patient and wound characteristics that may be clinically useful in the identification of wounds most likely to have retained glass. The role of radiographs as they are used in the evaluation of wounds caused by glass also was evaluated.
During the study period there were 36,467 patient visits to the ED. Of these, 5,208 (14%) h a d an open wound as one of the three p r i m a r y diagnoses. F o u r h u n d r e d thirty patients had a total of 578 glass-caused open wounds (comprising 8% of patients with open wounds). Wound evaluation was described as exploration or probing in 48% of the cases, irrigation in 44%, palpation in 2%, and not documented in 61%. Mean patient age was 30 years. The study included 286 (66%) men and 148 (34%) women. The racial mix was 139 caucasian (32%), 267 African-American (62%), 21 Hispanic (5%), and three Asian (< 1%). This sample is similar to our overall ED population, except a larger p r o p o r t i o n of the study population was male. Male patients make up 48% of the total ED population. The wound was described as a laceration in 557 wounds (96%) and a puncture in 21 wounds (4%). Median wound age was 1.2 hours (range, 0 to 96 hours), and median wound length was 2.5 cm (range, 0.2 to 20 cm). The wound was documented as deeper than the subcutaneous fat in 155 of the wounds (27%) and less than or equal to the subcutaneous fat in 278 of the cases (48%). No mention of wound depth was made in 145 cases (25%). The type of glass involved in causing the wounds was documented in 81% of cases. Windows (129, or 30%) and bottles (109, or 25%) accounted for the majority of injuries. Retained glass was found on exploration in 41 of 430 patients (9%) and 42 of 578 wounds (7%). In 25 patients, one piece of glass was removed; in seven patients, two pieces; and in six patients, more than two pieces of glass. Three patient records did not document the number of glass pieces removed. In 19 patients, the glass was less than 0.5 mm in diameter, and in eight patients, the glass was more than 1 cm in diameter, with the largest being 4 cm. In 14 wounds, the size of retained pieces of glass was not documented. Wounds of the head (P = .003) and foot (P < .0005) were more likely to have retained glass than were other wound sites (Table 1). Wounds of the hand (P = .001) were less likely to have retained glass. Motor vehicle accidents and stepping on glass were more likely to result in retained glass in the wound (P < .0005) than were other mechanisms of injury (Table 2). In addition, puncture wounds more often h a r b o r e d glass at ED presentation than did lacerations (P < .0005). Wound depth was not associated with retained glass (P = .69). One h u n d r e d thirty-seven radiographs were obtained in 133 patients (31%) with 174 wounds (30%). F o u r patients had two different anatomic sites radiographed. Eleven radiographs (8%) were positive, and 11 (8%) were indeterminate. In all indeterminate cases, clinical correlations suggested a low likelihood of foreign body retention. Of the 42 wounds positive for glass by exploration, seven (17%) had a positive r a d i o g r a p h before wound exploration. One patient h a d a piece of glass removed during initial h a n d wound exploration. A subsequent radiograph revealed an additional
MATERIALS
AND
METHODS
A retrospective evaluation was conducted of consecutive patients with wounds caused by glass between November 1, 1989, and October 31, 1990. Patients were treated in the ED of an u r b a n university hospital. Patients were treated by medical students, emergency medicine residents, and d e p a r t ment of emergency medicine faculty. All wounds initially assessed by a medical student also were evaluated by a postgraduate y e a r 3 emergency medicine resident or faculty member. All wound evaluation was determined by the treating physician, and no specific education or examination was included as p a r t of this study. The ED records for patients with wounds caused by glass were collected during the study period by an ED-based accredited medical records technician, who reviews and abstracts data from all ED medical records. A wound d a t a sheet was completed for each patient visit by one of the authors. Patient demographics included age, sex, and race. P r i m a r y wound d a t a included the location, type, age, length, and depth of the wound and whether glass was retained in the wound. Data regarding the injury included the mechanism and the type of glass that caused the injury. Information regarding the patient's perception as to whether glass was present in the wound also was collected. Data were collected for as many as three different wounds p e r patient. The r a d i o g r a p h interpretation was reviewed when radiography was performed. Radiology reports stating that a foreign body was present and correlating with the clinical presentation were considered positive. Reports that used the terms "questionable foreign b o d y " or "possible foreign body versus artifact" were labeled as indeterminate. The p r i m a r y purpose of this protocol was descriptive. The Z2 test was used to compare n o n p a r a m e t r i c wound characteristics.
NOVEMBER1992
21:11 ANNALSOF EMERGENCYMEDICINE
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FOREIGN BODIES Montano, Steele & Watson
piece of glass that was removed at re-exploration. In one patient, a radiograph suggested a 1-mm foreign body, but subsequent wound exploration was negative for retained glass. The patient's perception as to whether glass remained in the wound was recorded in 165 cases (38%); 42 patients (25%) said that glass remained in their wound(s), and 123 patients (75%) stated that glass did not remain in their wound(s). Patients who stated that it felt like there was glass in the wound were more likely to have glass found by exploration (15 of 41, P < .0005) and r a d i o g r a p h y (five of l 1, P = .043) than those who did not have that perception.
We are unaware of previous studies that have attempted to characterize wounds caused specifically by glass or identify the characteristics of wounds with retained glass. We hypothesized that puncture wounds caused by glass would have retained glass more often than would lacerations. This was confirmed by our data. We also predicted that lacerations extending beyond the subcutaneous tissue would retain foreign bodies more often; however, this was not the case. The likelihood of retention if the glass was b r o k e n could not be assessed due to insufficient documentation of this information. In addition, we were interested in the patient's perception as to whether glass remained in the wound. Retained glass was more likely to be present if the patient had a foreign body sensation. The anatomic sites commonly associated with retained glass were described by Gron et al. 2 In their series, in 16 of 27 patients, glass foreign bodies were located in the fingers
or hand, ten were in the foot, and one was in the forearm. Our series differed from that of Gron et al in that the head region accounted for the largest n u m b e r of patients with retained glass. In addition, only 12% of our patients had retained glass in the h a n d compared with 59% in their study. In our series, the h a n d was less likely to have retained glass compared with other anatomic sites even though h a n d wounds caused by glass made up 35% of our cases. The majority of studies 2-7,10-]8 involving glass foreign bodies have been designed to determine whether glass will show up on plain radiography. We also looked at what type of patient had r a d i o g r a p h y performed and how often the radiographs were positive. About one third of patients in our series had r a d i o g r a p h y performed, with 8% of patients having positive results. Patients with wounds of the foot, arm, and wrist were more likely to have radiography, whereas wounds of the head were found more often to contain foreign bodies. P u n c t u r e wounds yielded more positive radiographs than did lacerations, which is similar to the results of exploration. A positive patient perception also correlated with a positive radiograph. These findings suggest that radiographs may be useful for determining the presence of retained glass in puncture wounds and deep lacerations, wounds of the foot, and wounds in which the patient believes there is glass retention but wound exploration does not identify the presence of glass. In this series, two cases had a negative wound exploration followed by a positive radiograph. One case involved a small laceration of the distal finger. The r a d i o g r a p h demonstrated a 1- to 2-mm foreign body that was not found on subsequent re-exploration. In the second case, initial exploration of a
Table 1. Exploration for wound foreign bodies by location and mechanism of injury
Table 2. Radiographs for wound foreign bodies by location and mechanism of i n jury
DISCUSSION
Wound Location Hand Forearm/wrist Head Arm Foot Leg Other Total Wound Mechanism Struck by glass Hand put through glass Fell on glass Washing dishes Stepped on glass Motor vehicle accident Other Net specified Tatal
78/1362
Total (%)
Glass Foreign Body Found by Exploration (%)
204 (35) 122 (21) 114 (20) 39 (7) 35 (6) 31 (5) 33 (6) 578
5 (12) 5 (12) 17 (40) 1 (2,5) 10 (24) 1 (2.5) 3 (7) 42
109 (25) 91 (21) 44 (10) 28 (7) 22 (5) 18 (4) 56 (13) 62 ('14) 430
7 (17) 4 (10) 5 (12) 0 8 (20) 14 (34) 2 (5) 1 (2) 41
Radiographs
Wound Location Hand Forearm/wrist Head Arm Foot Leg Other Total Wound Mechanism Struck by glass Hand putthrough glass Fell on glass Washing dishes Stepped on glass Motor vehicle accident Other Not specified Total
Total (%)
Positive (%)
69 (40) 33 (19) 27 (16) 5 (3) 13 (7) 20 (11) 7 (4) 174
4 (37) 2 (18) 1 (9) 1 (9) 3 (27) 0 0 11
36 (27) 28 (21) 17 (13) 1 (1) 13 (10) 6 (4) 20 (15) 12 (9) 133
1 (9) I (9) 2 (18) 0 3 (28) 2 (18) 2 (18) 0 11
ANNALS OF EMERGENCYMEDJCINE 21:11 NOVEMBER1992
FOREIGN BODIES Montano, Steele & Watson
hand wound revealed a small piece of glass. A r a d i o g r a p h revealed a second small piece within the same wound, which then was removed. In two cases, foreign bodies were found on r a d i o g r a p h y after superficial evaluation of the wounds. In the first case, the patient had a large elbow laceration and some superficial puncture wounds on his u p p e r arm. The laceration was thoroughly explored, debrided, and sutured. The punctures were inspected and palpated but not explored. Radiography revealed a 3-mm piece of glass, which then was removed. The other case involved a laceration of the sole of the foot. The physician inspected and p a l p a t e d the wound, but no exploration was carried out. A r a d i o g r a p h revealed a piece of glass that was removed easily after wound exploration. In the study conducted by Gron et al, nine patients had an initial negative clinical examination that was p r i m a r i l y inspection of the wound. 2 Other studies1, 4 also have suggested that clinical examination is insufficient to exclude the presence of retained glass, but no definition of the clinical examination was provided to assess their thoroughness. Thus, wound inspection and palpation alone are insufficient to rule out retained glass. P a l p a t i o n was documented infrequently in this series; exploration, probing, and irrigation accounted for 405 of 430 cases (94%). The retrospective n a t u r e of the study resulted in incomplete data for some parameters. A well-designed prospective study would be necessary to remedy this problem. Two thirds of our patients did not have radiographs taken, the current gold s t a n d a r d for ruling out the presence of glass. This may have resulted in underestimation of the true incidence of retained glass in our series. Although our findings are valid in describing the characteristics of glass-caused wounds, they are at best suggestive of when to use radiography in identifying retained glass.
1. Anderson MA: Diagnosis and treatment of retained foreign bodies in the hand. Am J Surg 1982;144:63-67. 2. 6ran P, Anderson K, Vraa A: Detection of glass foreign bodies by radiography. Injury 198fi;17:404-406, 3. Stein F: Foreign body injuries of the hand. Emerg Med Clin North Am t985;3:383-390. 4, Browett JP, Fiddian NJ: Delayed median nerve injury due to retained glass fragments. J Bone Joint Surg 1985;67:382-384. 5. Cameron JD: The treatment of glass injuries to the hand at work. Hand1970;2:52-55. 6. Jennett WB, Watson JA: The radio-opacity of glass foreign bodies. BrJ Surg
1958;46:244-246. 7. Lammers RL: Soft tissue foreign bodies. Ann Emerg Meal 1988;17:1336-1344. 8. Morgan W J, Leopold T, Evans R: Foreign bodies in hand. JHand Surg 1984;9B:lg4196. 9. Tandberg D: 61ass in the hand and foot: Will an x-ray show it? JAMA 1982;248:18681874. 10, Courter BJ: Radiographic screening for glass foreign bodies--What does a "negative" foreign body series really mean? Ann Emerg Meal 1990;19:997-1000. 11. Whelan 6P: The radiopacity of glass in soft tissue. JAOEP 1975;4:401-402. 12, deLacey G, Evans R, Sardin B: Penetrating injuries: How easy is itto see glass (and plastic) on radiographs? BrJRadia11985;58:27-30. 13. Felrnan AH, Fisher MS: Detection of glass in soft tissue by x-ray. Pediatrics
1970;45:478-480, 14, Felrnan AH, Fisher MS: The radiographic detection of glass in soft tissue. Radiology 1969;92:1529-1531. 15. Fordharn SD: The detection of glass foreign bodies. South MedJ 1976;69:1484-1485. 16, Langsarn A: Solid foreign bodies in soft tissue: Diagnosis and management. Delaware Med J 1985;57:693-701. 17. Pond GD, Lindsey D: Localization of cactus, glass, and other foreign bodies in soft tissues. Ariz Med 1977;34:700-701. 18.6insburg M J, Ellis GL, Florn L: Detection of soft-tissue foreign bodies by plain radiography, xerography, computed tornography, and ultrasonography. Ann Ernerg Mefl 1990;19:701-703, The authors thank Nancy A Stratton, ART, for her diligent identification of glasscaused wound cases.
CONCLUSION
Glass was found on exploration in 7% of wounds in this series. Eleven of 137 radiographs (8%) were positive, and an additional 8% were indeterminate. The wounds most likely to have retained glass were puncture wounds and head or foot wounds. Wounds caused by stepping on glass or by a motor vehicle accident also were more likely to have a retained glass foreign body. Finally, patients who stated that they had the perception of glass retention were also more likely to h a r b o r a glass foreign body. Although prospective studies are necessary to clarify indications for radiography in patients with glass-caused wounds, these results suggest that the presence of a number of wound characteristics should alert the chnician to a higher likelihood of retained glass being present.
NOVEMBER1992
REFERENCES
21:11
ANNALS 0F EMERGENCY MEDICINE
Address for reprints: William A Watson, PharmD, DABAT Department of Emergency Medicine Truman Medical Center 2301 Holmes Street Kansas City, Missouri 64108
1363/79
foreign body, diagnosis
Foreign Body Retention in Glass-Caused Wounds From the University of MissouriKansas City School of Medicine, Department of Emergency Medicine;* Truman Medical Center;t and the University of Missouri-Kansas City School of Pharmacy, t Kansas City, Missouri. Received for publication September 6, 1991. Revision received June 5, 1992. Accepted for publication June 14, 1992.
Julian B Montano, MD*
Study objective: Todescribe patient and wound characteristics
Mark T Steele, MD, FACEP*t
that are clinically useful in identifying wounds that were caused by glass and retained a foreign body.
William A Watson, PharmD, DABATr~
Design: Retrospective consecutive case review.
Setting: Urban, university-affiliated teaching hospital. Type of participants: Four hundred thirty consecutive patients with a total of 578 evaluable wounds caused by glass during a 12-month period. Measurements and results: Medical records were reviewed to
determine patient demographics, primary wound data (eg, location, type, description), mechanism of injury, type of glass involved, and presence of foreign body sensation. 61ass was found by examination in 7% of wounds. Eight percent of 137 radiographs were positive. Wounds with the highest prevalence of retained glass were puncture wounds (P< .0005), those caused by stepping on glass or by a motor vehicle accident (P< .005), and those of the head or foot (P< .003).
Conclusion: Characteristics of wounds most likely to retain glass were identified in this retrospective study. The presence of these factors should increase the clinician's suspicion of a retained glass foreign body. The indications for radiography for the detection of retained glass in wounds should be clarified with prospective studies. [Montano JB, Steele MT, Watson WA: Foreign body retention in glass-caused wounds. Ann EmergMedNovember 1992;21: 1360-1363.]
76/1360
ANNALS OF EMERGENCY MEDIOINE 21:11 NOVEMBER1092
FOREIGN B O D I E S
Montano, Steele & Watson
INTRODUCTION
RESULTS
GLass is a frequent cause of wounds in patients who present to the emergency department. Most wounds are thought to not have retained glass, but no data exist to verify this observation. It also is unknown whether routine clinical examination or wound exploration will identify retained glass pieces. Glass detection can be difficult in some wounds. 1-3 Residual material can r e s u l t in delayed wound healing, infection, and tissue damage; 3-a therefore, detection is important. Plain radiographs can help confirm the presence or absence of glass in cases where wound exploration is difficult.9,1° There are no clinical predictors for wounds at high risk for glass retention that can be used as an indication for radiographic studies. We conducted a retrospective study to describe patient and wound characteristics that may be clinically useful in the identification of wounds most likely to have retained glass. The role of radiographs as they are used in the evaluation of wounds caused by glass also was evaluated.
During the study period there were 36,467 patient visits to the ED. Of these, 5,208 (14%) h a d an open wound as one of the three p r i m a r y diagnoses. F o u r h u n d r e d thirty patients had a total of 578 glass-caused open wounds (comprising 8% of patients with open wounds). Wound evaluation was described as exploration or probing in 48% of the cases, irrigation in 44%, palpation in 2%, and not documented in 61%. Mean patient age was 30 years. The study included 286 (66%) men and 148 (34%) women. The racial mix was 139 caucasian (32%), 267 African-American (62%), 21 Hispanic (5%), and three Asian (< 1%). This sample is similar to our overall ED population, except a larger p r o p o r t i o n of the study population was male. Male patients make up 48% of the total ED population. The wound was described as a laceration in 557 wounds (96%) and a puncture in 21 wounds (4%). Median wound age was 1.2 hours (range, 0 to 96 hours), and median wound length was 2.5 cm (range, 0.2 to 20 cm). The wound was documented as deeper than the subcutaneous fat in 155 of the wounds (27%) and less than or equal to the subcutaneous fat in 278 of the cases (48%). No mention of wound depth was made in 145 cases (25%). The type of glass involved in causing the wounds was documented in 81% of cases. Windows (129, or 30%) and bottles (109, or 25%) accounted for the majority of injuries. Retained glass was found on exploration in 41 of 430 patients (9%) and 42 of 578 wounds (7%). In 25 patients, one piece of glass was removed; in seven patients, two pieces; and in six patients, more than two pieces of glass. Three patient records did not document the number of glass pieces removed. In 19 patients, the glass was less than 0.5 mm in diameter, and in eight patients, the glass was more than 1 cm in diameter, with the largest being 4 cm. In 14 wounds, the size of retained pieces of glass was not documented. Wounds of the head (P = .003) and foot (P < .0005) were more likely to have retained glass than were other wound sites (Table 1). Wounds of the hand (P = .001) were less likely to have retained glass. Motor vehicle accidents and stepping on glass were more likely to result in retained glass in the wound (P < .0005) than were other mechanisms of injury (Table 2). In addition, puncture wounds more often h a r b o r e d glass at ED presentation than did lacerations (P < .0005). Wound depth was not associated with retained glass (P = .69). One h u n d r e d thirty-seven radiographs were obtained in 133 patients (31%) with 174 wounds (30%). F o u r patients had two different anatomic sites radiographed. Eleven radiographs (8%) were positive, and 11 (8%) were indeterminate. In all indeterminate cases, clinical correlations suggested a low likelihood of foreign body retention. Of the 42 wounds positive for glass by exploration, seven (17%) had a positive r a d i o g r a p h before wound exploration. One patient h a d a piece of glass removed during initial h a n d wound exploration. A subsequent radiograph revealed an additional
MATERIALS
AND
METHODS
A retrospective evaluation was conducted of consecutive patients with wounds caused by glass between November 1, 1989, and October 31, 1990. Patients were treated in the ED of an u r b a n university hospital. Patients were treated by medical students, emergency medicine residents, and d e p a r t ment of emergency medicine faculty. All wounds initially assessed by a medical student also were evaluated by a postgraduate y e a r 3 emergency medicine resident or faculty member. All wound evaluation was determined by the treating physician, and no specific education or examination was included as p a r t of this study. The ED records for patients with wounds caused by glass were collected during the study period by an ED-based accredited medical records technician, who reviews and abstracts data from all ED medical records. A wound d a t a sheet was completed for each patient visit by one of the authors. Patient demographics included age, sex, and race. P r i m a r y wound d a t a included the location, type, age, length, and depth of the wound and whether glass was retained in the wound. Data regarding the injury included the mechanism and the type of glass that caused the injury. Information regarding the patient's perception as to whether glass was present in the wound also was collected. Data were collected for as many as three different wounds p e r patient. The r a d i o g r a p h interpretation was reviewed when radiography was performed. Radiology reports stating that a foreign body was present and correlating with the clinical presentation were considered positive. Reports that used the terms "questionable foreign b o d y " or "possible foreign body versus artifact" were labeled as indeterminate. The p r i m a r y purpose of this protocol was descriptive. The Z2 test was used to compare n o n p a r a m e t r i c wound characteristics.
NOVEMBER1992
21:11 ANNALSOF EMERGENCYMEDICINE
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FOREIGN BODIES Montano, Steele & Watson
piece of glass that was removed at re-exploration. In one patient, a radiograph suggested a 1-mm foreign body, but subsequent wound exploration was negative for retained glass. The patient's perception as to whether glass remained in the wound was recorded in 165 cases (38%); 42 patients (25%) said that glass remained in their wound(s), and 123 patients (75%) stated that glass did not remain in their wound(s). Patients who stated that it felt like there was glass in the wound were more likely to have glass found by exploration (15 of 41, P < .0005) and r a d i o g r a p h y (five of l 1, P = .043) than those who did not have that perception.
We are unaware of previous studies that have attempted to characterize wounds caused specifically by glass or identify the characteristics of wounds with retained glass. We hypothesized that puncture wounds caused by glass would have retained glass more often than would lacerations. This was confirmed by our data. We also predicted that lacerations extending beyond the subcutaneous tissue would retain foreign bodies more often; however, this was not the case. The likelihood of retention if the glass was b r o k e n could not be assessed due to insufficient documentation of this information. In addition, we were interested in the patient's perception as to whether glass remained in the wound. Retained glass was more likely to be present if the patient had a foreign body sensation. The anatomic sites commonly associated with retained glass were described by Gron et al. 2 In their series, in 16 of 27 patients, glass foreign bodies were located in the fingers
or hand, ten were in the foot, and one was in the forearm. Our series differed from that of Gron et al in that the head region accounted for the largest n u m b e r of patients with retained glass. In addition, only 12% of our patients had retained glass in the h a n d compared with 59% in their study. In our series, the h a n d was less likely to have retained glass compared with other anatomic sites even though h a n d wounds caused by glass made up 35% of our cases. The majority of studies 2-7,10-]8 involving glass foreign bodies have been designed to determine whether glass will show up on plain radiography. We also looked at what type of patient had r a d i o g r a p h y performed and how often the radiographs were positive. About one third of patients in our series had r a d i o g r a p h y performed, with 8% of patients having positive results. Patients with wounds of the foot, arm, and wrist were more likely to have radiography, whereas wounds of the head were found more often to contain foreign bodies. P u n c t u r e wounds yielded more positive radiographs than did lacerations, which is similar to the results of exploration. A positive patient perception also correlated with a positive radiograph. These findings suggest that radiographs may be useful for determining the presence of retained glass in puncture wounds and deep lacerations, wounds of the foot, and wounds in which the patient believes there is glass retention but wound exploration does not identify the presence of glass. In this series, two cases had a negative wound exploration followed by a positive radiograph. One case involved a small laceration of the distal finger. The r a d i o g r a p h demonstrated a 1- to 2-mm foreign body that was not found on subsequent re-exploration. In the second case, initial exploration of a
Table 1. Exploration for wound foreign bodies by location and mechanism of injury
Table 2. Radiographs for wound foreign bodies by location and mechanism of i n jury
DISCUSSION
Wound Location Hand Forearm/wrist Head Arm Foot Leg Other Total Wound Mechanism Struck by glass Hand put through glass Fell on glass Washing dishes Stepped on glass Motor vehicle accident Other Net specified Tatal
78/1362
Total (%)
Glass Foreign Body Found by Exploration (%)
204 (35) 122 (21) 114 (20) 39 (7) 35 (6) 31 (5) 33 (6) 578
5 (12) 5 (12) 17 (40) 1 (2,5) 10 (24) 1 (2.5) 3 (7) 42
109 (25) 91 (21) 44 (10) 28 (7) 22 (5) 18 (4) 56 (13) 62 ('14) 430
7 (17) 4 (10) 5 (12) 0 8 (20) 14 (34) 2 (5) 1 (2) 41
Radiographs
Wound Location Hand Forearm/wrist Head Arm Foot Leg Other Total Wound Mechanism Struck by glass Hand putthrough glass Fell on glass Washing dishes Stepped on glass Motor vehicle accident Other Not specified Total
Total (%)
Positive (%)
69 (40) 33 (19) 27 (16) 5 (3) 13 (7) 20 (11) 7 (4) 174
4 (37) 2 (18) 1 (9) 1 (9) 3 (27) 0 0 11
36 (27) 28 (21) 17 (13) 1 (1) 13 (10) 6 (4) 20 (15) 12 (9) 133
1 (9) I (9) 2 (18) 0 3 (28) 2 (18) 2 (18) 0 11
ANNALS OF EMERGENCYMEDJCINE 21:11 NOVEMBER1992
FOREIGN BODIES Montano, Steele & Watson
hand wound revealed a small piece of glass. A r a d i o g r a p h revealed a second small piece within the same wound, which then was removed. In two cases, foreign bodies were found on r a d i o g r a p h y after superficial evaluation of the wounds. In the first case, the patient had a large elbow laceration and some superficial puncture wounds on his u p p e r arm. The laceration was thoroughly explored, debrided, and sutured. The punctures were inspected and palpated but not explored. Radiography revealed a 3-mm piece of glass, which then was removed. The other case involved a laceration of the sole of the foot. The physician inspected and p a l p a t e d the wound, but no exploration was carried out. A r a d i o g r a p h revealed a piece of glass that was removed easily after wound exploration. In the study conducted by Gron et al, nine patients had an initial negative clinical examination that was p r i m a r i l y inspection of the wound. 2 Other studies1, 4 also have suggested that clinical examination is insufficient to exclude the presence of retained glass, but no definition of the clinical examination was provided to assess their thoroughness. Thus, wound inspection and palpation alone are insufficient to rule out retained glass. P a l p a t i o n was documented infrequently in this series; exploration, probing, and irrigation accounted for 405 of 430 cases (94%). The retrospective n a t u r e of the study resulted in incomplete data for some parameters. A well-designed prospective study would be necessary to remedy this problem. Two thirds of our patients did not have radiographs taken, the current gold s t a n d a r d for ruling out the presence of glass. This may have resulted in underestimation of the true incidence of retained glass in our series. Although our findings are valid in describing the characteristics of glass-caused wounds, they are at best suggestive of when to use radiography in identifying retained glass.
1. Anderson MA: Diagnosis and treatment of retained foreign bodies in the hand. Am J Surg 1982;144:63-67. 2. 6ran P, Anderson K, Vraa A: Detection of glass foreign bodies by radiography. Injury 198fi;17:404-406, 3. Stein F: Foreign body injuries of the hand. Emerg Med Clin North Am t985;3:383-390. 4, Browett JP, Fiddian NJ: Delayed median nerve injury due to retained glass fragments. J Bone Joint Surg 1985;67:382-384. 5. Cameron JD: The treatment of glass injuries to the hand at work. Hand1970;2:52-55. 6. Jennett WB, Watson JA: The radio-opacity of glass foreign bodies. BrJ Surg
1958;46:244-246. 7. Lammers RL: Soft tissue foreign bodies. Ann Emerg Meal 1988;17:1336-1344. 8. Morgan W J, Leopold T, Evans R: Foreign bodies in hand. JHand Surg 1984;9B:lg4196. 9. Tandberg D: 61ass in the hand and foot: Will an x-ray show it? JAMA 1982;248:18681874. 10, Courter BJ: Radiographic screening for glass foreign bodies--What does a "negative" foreign body series really mean? Ann Emerg Meal 1990;19:997-1000. 11. Whelan 6P: The radiopacity of glass in soft tissue. JAOEP 1975;4:401-402. 12, deLacey G, Evans R, Sardin B: Penetrating injuries: How easy is itto see glass (and plastic) on radiographs? BrJRadia11985;58:27-30. 13. Felrnan AH, Fisher MS: Detection of glass in soft tissue by x-ray. Pediatrics
1970;45:478-480, 14, Felrnan AH, Fisher MS: The radiographic detection of glass in soft tissue. Radiology 1969;92:1529-1531. 15. Fordharn SD: The detection of glass foreign bodies. South MedJ 1976;69:1484-1485. 16, Langsarn A: Solid foreign bodies in soft tissue: Diagnosis and management. Delaware Med J 1985;57:693-701. 17. Pond GD, Lindsey D: Localization of cactus, glass, and other foreign bodies in soft tissues. Ariz Med 1977;34:700-701. 18.6insburg M J, Ellis GL, Florn L: Detection of soft-tissue foreign bodies by plain radiography, xerography, computed tornography, and ultrasonography. Ann Ernerg Mefl 1990;19:701-703, The authors thank Nancy A Stratton, ART, for her diligent identification of glasscaused wound cases.
CONCLUSION
Glass was found on exploration in 7% of wounds in this series. Eleven of 137 radiographs (8%) were positive, and an additional 8% were indeterminate. The wounds most likely to have retained glass were puncture wounds and head or foot wounds. Wounds caused by stepping on glass or by a motor vehicle accident also were more likely to have a retained glass foreign body. Finally, patients who stated that they had the perception of glass retention were also more likely to h a r b o r a glass foreign body. Although prospective studies are necessary to clarify indications for radiography in patients with glass-caused wounds, these results suggest that the presence of a number of wound characteristics should alert the chnician to a higher likelihood of retained glass being present.
NOVEMBER1992
REFERENCES
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