Letters to Editor

Ultrasonographic delineation of a foreign body in the calf Sir, An 8-year-old boy came with a history of painful swelling of his left leg and discharging sinuses (at the medial and lateral aspect) for the last 4 months. There was history of fever. Detailed history revealed that about 6 months ago, he fell down from the roof of his house on a tree and sustained injury. He was treated locally and pieces of wood were removed from the wound and then sutured. The wound healed temporarily. After 2 months he developed swelling and draining sinuses in his left leg. At the time of admission, his laboratory results were normal except for low hemoglobin level. Plain radiography of the leg showed soft tissue thickening leg with obliteration of fat planes in the calf region. No foreign body could be identified. Using a high frequency linear probe, ultrasonography (USG) was done, which revealed a linear echogenic focus of 3.2 cm size and 4-5 mm thickness with posterior shadowing at the postero-medial aspect of his left leg intramuscularly, just subjacent to the medial external skin opening [Figure 1]. A thin hypoechoic tract was seen extending obliquely between the two external skin openings along the echogenic focus/foreign body. Soft tissue edema and inflammatory changes noted around the lesion. No pus was expressed out at the time of examination. Subsequently the patient was taken for exploration of the wound and a wooden piece was removed [Figure 2]. Patient was continued on antibiotics. On follow-up, the swelling has decreased and skin opening of the sinuses showed healing without any discharge. The imaging appearance of wooden foreign bodies is variable.[1-3] Plain radiographs did not reveal the foreign body due to its radiolucent nature. Wood was highly echogenic and revealed pronounced acoustic shadowing on sonography. In computed tomography (CT) retained wood appears as isodense or subtle hyperdense focus. With magnetic resonance imaging (MRI), wooden foreign bodies show variable signal intensity that was equal to or less than that of skeletal muscle on both T1- and T2-weighted images. Though MRI shows the surrounding inflammatory response better than CT, a painful swollen softtissue mass or pseudotumor may suggest the possibility of malignancy or infection, rather than indicating a retained foreign body.[4] A history of recurrent localized infections with or without sinus formation should prompt a search for an occult foreign body.[5] Remote trauma, however trivial, should lead to search for missed foreign body, particularly in children. Wood, with its porous consistency and organic nature, is an excellent medium for microorganisms, and the retained wooden foreign matter may Journal of Emergencies, Trauma, and Shock I 6:4 I Oct - Dec 2013

Figure 1: Ultrasonography (USG) in calf region shows linear echogenic focus of foreign body with surrounding hypoechoic edema

Figure 2: Photograph of wooden foreign body after its removal

result in cellulitis, abscess, and sinus or fistula formation. CT is reserved for deep foreign bodies or when foreign bodies are not seen on radiographs or USG but are still suspected or to confirm the plane of the foreign body detected on USG. Davae et al.,[6] used power Doppler to delineate soft tissue foreign bodies and found surrounding hypervascularity reflecting neovascularity of the reactive granuloma. USG can also aid in guiding the extraction or retrieval of the foreign body.

Shanmugapriya Gnanavel, Nagarajan Krishnan, Kalpana Raja, Srinivasan Subbiah1 Departments of Radiology and General Surgery1 Sri Manakula Vinayagar Medical College, Pondicherry - 605 107, India. E-mail: [email protected] 307

Letters to Editor

REFERENCES 1.

Fornage BD, Schernberg FL. Sonographic diagnosis of foreign bodies of the distal extremities. AJR Am J Roentgenol 1986;147:567-9.

2.

Bauer AR Jr, Yutani D. Computed tomographic localization of wooden foreign bodies in children’s extremities. Arch Surg 1983;118:1084-6.

3.

Boyse TD, Fessell DP, Jacobson JA, Lin J, van Holsbeeck MT, Hayes CW. US of soft tissue foreign bodies and associated complications with surgical correlation. Radiographics 2001;21:1251-6.

4.

Yanay O, Vaughan DJ, Diab M, Brownstein D, Brogan TV. Retained wooden foreign body in a child’s thigh complicated by severe necrotizing fasciitis: A case report and discussion of imaging modalities for early diagnosis. Pediatr Emerg Care 2001;17:354-5.

5.

Gulati D, Agarwal A. Wooden foreign body in the forearm — presentation after eight years. Ulus Travma Acil Cerrahi Derg 2010;16:373-5.

6.

Davae KC, Sofka CM, DiCarlo E, Adler RS. Value of power Doppler imaging and the hypoechoic halo in the sonographic detection of foreign bodies: Correlation with histopathologic findings. J Ultrasound Med 2003;22:1309-13.

peritoneal lavage or surgery to assess the diagnostic value of ultrasonography. The Epi Info statistical software version 3.4.1 was used for data analysis. By scanning to detect free fluid, sensitivity, specificity, positive and negative predictive values and the diagnostic accuracy were 96%, 67%, 94%, 75%, and 91% respectively. By scanning to detect the parenchymal injury, sensitivity, specificity, positive and negative predictive values and diagnostic accuracy were 71%, 35%, 62%, 44%, and 56% respectively. In conclusion, ultrasonography has a high diagnostic value in the screening of patients with blunt abdominal trauma. Scanning for the presence of free fluid yields better results than scanning for the visceral parenchymal injury.

Michael I Nnamonu Department of Surgery, Jos University Teaching Hospital, Jos, Nigeria E-mail: [email protected]

Access this article online Quick Response Code: Website: www.onlinejets.org

DOI: 10.4103/0974-2700.120393

Diagnostic value of abdominal ultrasonography in patients with blunt abdominal trauma Sir, Despite the trend to comprehensively investigate the patients with blunt abdominal trauma with a computerized tomography scan, diagnostic ultrasonography remains an important tool more so where computed tomography is not available or condition of the patient precludes transfer to the radiology suite.[1-3] This study assessed the diagnostic value of ultrasonography in blunt abdominal injury. It was a prospective study conducted at the Department of Surgery, Jos University Teaching Hospital from 1 January 2006 to 31 December 2007. Fifty-seven patients who had ultrasonography for blunt abdominal trauma had their sonographic findings compared with findings at diagnostic 308

REFERENCES 1.

Stengel D, Bauwens K, Porzsolt F, Rademacher G, Mutze S, Ekkernkamp A. Emergency ultrasound for blunt abdominal trauma – Meta-analysis update 2003. Zentralbl Chir 2003;128:1027-37.

2.

Breyer B, Bruguera CA, Gharbi HA, Goldberg BB, Tan FE, Wachira MW. Preface. In: Palmer PE, editor. Manual of Diagnostic Ultrasound. Geneva: World Health Organization; 2004. p. vii-viii.

3.

Yoshii H, Sato M, Yamamoto S, Motegi M, Okusawa S, Kitano M, et al. Usefulness and limitations of ultrasonography in the initial evaluation of blunt abdominal trauma. J Trauma 1998;45:45-50. Access this article online Quick Response Code: Website: www.onlinejets.org

DOI: 10.4103/0974-2700.120395

Bilateral luxatio erecta humeri with a unilateral brachial plexus injury Sir, Luxatio erecta is a rare inferior glenohumeral dislocation accounting for only 0.5% of all shoulder dislocations.[1] Bilateral Journal of Emergencies, Trauma, and Shock I 6:4 I Oct - Dec 2013

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Ultrasonographic delineation of a foreign body in the calf.

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