n Identification of foreign body on plain film or ultrasound
n Saphenous or posterior tibial nerve block
n Enlargement of the wound or entrance site using incision or skin cutting
n Blunt or sharp dissection of the associated tissue
n Foreign body removal using fluoroscopy
n Copious irrigation
n Close follow-up with podiatry
n Infection risk considerations, antibiotic coverage, and proper dressing
Are you prepared to get leaded up? You need to wear lead protection while doing this procedure. Be sure to remove any excess clothing or equipment before starting, and wear upper and lower lead in the radiology testing area (or even if you are using the portable C-arm). A thyroid protector is always suggested. If you are pregnant, we suggest opting out of performing the procedure, although studies have shown it is safe as long as you are properly covered. The guidelines for lead wear are standard per your facility. Most lead coats range from seven to 15 pounds, depending on the type and the amount of surface area requiring coverage.
n Obtain radiographs of the affected area. The plantar portion of the foot was involved in this case so we obtained initial lateral and AP films of the foot. (NOTE: If the foreign body is known to be plastic or wood, fluoroscopy may not be a suitable choice for removal.)
n Contact the radiology tech post-identification of the foreign body and inquire about the C-arm. Occasionally, this can be taken to the bedside, and other times it must be used in the radiology treatment area. (NOTE: You will have already checked your department policy. Do not try to sort this out in real time.)
n Order continuous fluoroscopy in your EMR. For those of you still using paper, an order is required either way. You also need to document indications and alternatives for billing purposes.
n Obtain warm water bath with soap and water, antiseptic, suture tray or kit (curved hemostat, forceps), sterile gloves, sterile towels, marking pen, 11 blade scalpel, 27 g needle, 18 g needle, 10 mL syringe, lidocaine 1% with bupivicane 0.5%, and sodium bicarbonate.
n Combine 5 mL of lidocaine with 4 mL of bupivacaine with 1 mL of sodium bicarbonate for nerve block.
n Soak the foot in a warm soap water bath for five to 10 minutes to loosen skin and clean area. Then use an antiseptic like chlorhexidine to copiously clean the area.
n Use the pen to mark your site.
n Perform posterior tibial nerve or saphenous nerve block. (Nerve blocks will be covered in future blog series.)
n A local injection can be used, but often may not as effective as a full block.
It is important to know the approximate (if not exact) location of the foreign body because lower extremity blocks have specific areas of innervation. The nerve block is highly favored with additional anesthesia added to the site if needed.
n Consider using LET in the affected area for additional anesthesia. This can be applied in triage or prior to going to the treatment area.
n Wrap a sterile towel around the ankle. This will help you move and reposition the ankle and foot while you are involved in the sterile procedure.
n Position the patient in a supine position. As stressed in the past, positioning is half the battle and can make or break your procedure. Provide comfort for the patient with pillows or padding, use adequate lighting and height of your workspace, and have the nurse administer pain medication as needed. This allows for proper visualization, inspection, and timely management. (Emerg Med Clin North Am 2003;21:205.)
n Shield your patient with proper lead attire.
n Position the C-arm appropriately over the affected area. (See video for actual positioning techniques.) The technician can help guide you and start your “exposure clock.” They are excellent resources during the procedure, and we suggest you check in with them often by asking how much time you have left.
n Use the same pen to act as an identifier for placement when using the scout shots to locate the FB. Mark the area on the foot.
n Make an incision over the area of interest with an 11-blade scalpel. Directly visualize the area without any probing to see if the object is visible and removable.
n If not visualized, shoot another scout shot to determine depth of the foreign body while inserting your hemostat or forceps. This is when the continuous fluoroscopy may be of most help. As you approach the object, you will be able to see it in real time and localize it.
n Once localized, remove the foreign body with hemostat or forceps. Tweezers should NOT be used because they do not close fully around most metal or glass objects.
n Irrigate the area. Large volumes should be considered, 300-500 mL. You must remove all foreign body material to avoid infection. Consider using a 10 mL syringe with splashguard to forcefully inject irrigation fluid. With that being said, application of “povidone-iodine solution, hydrogen peroxide, or detergents to irritant solutions should be avoided because of their cytotoxic properties and lack of significant bactericidal action.” (Ann Emerg Med 1999;34:356.)
n We also suggest using tap water because it is cheaper and creates less waste. It is also just as effective. (See tip below.)
n Depending on the incision you have made, you may want to consider closing the area with loosely approximated sutures. This approach is controversial and should be discussed with a podiatrist. If it is a small incision, no closure is needed, and a bulky dressing, cast shoe, and crutch should be used for a week to 10 days. Crutch or walker use is important because it will help relieve the pressure on the site. It is also important to encourage the patient to rest the extremity.
n Antibiotics: Yes for diabetics. We suggest staph and strep coverage with a cephalosporin such as Keflex. If the patient has a history of MRSA, you may want to consider culturing the site if it is an old, infected foreign body. One dose of IV Invanz or Ancef may also be considered. You must also consider coverage for Pseudomonas, so adding Cipro may be a solid choice.
n Update the tetanus shot if indicated.
Please see our video for exact technique by clicking here.
Cautions and Pearls
n Consider the indications for foreign body removal first. Is there neurovascular compromise? Evidence of infection? Is it causing a cosmetic deformity? If it is causing a functional impairment or chronic pain or if the patient requests it, you should be gearing up to go to fluoro.
n If the patient has none of the above and would prefer the specialist, consider referral at that time. Also consider signs of sepsis or bacteremia if the site appears cellulitic or more extensively compromised.
n Consider patients with diabetes, HIV, PVD, or other immunocompromised disorders to be delicate, and treat them with prophylactic antibiotics.
n Contraindications include deep embedding, neurovascular compromise, poor or inadequate information about the foreign body, and risks for severe bleeding (i.e., bleeding disorders, medications). These issues should be considered high-risk, and the foreign body may best treated in the operating room or by podiatry directly. (Emerg Med Australas 2013;25:603.)
n Set the patient up for success at the start. Many patients have expectations that the foreign body can easily be removed without much damage or complication. This might be the case, but sometimes it is not reasonable. Discuss risks and benefits with the patient upfront and why or why not the procedure should be completed.
n Have the patient sign a consent form with the risk-benefit discussion documented, and send a copy of that form home with them. Your paperwork should also include names of follow-up personnel, expected recovery course, signs and symptoms of infection, and the potential for retained foreign body. Nerve damage is also a concern, and should be discussed with the patient every time. Proper dressings, wound care technique, and extremity care should also be discussed ad nauseum.
The American College of Radiology recommends that your consent form state:
“Before the proposed procedure is performed, the following will be explained to the patient or, if the patient is unable to provide consent, to the patient’s legal representative:
“a. The purpose and nature of the procedure or treatment.
“b. The method by which the procedure or treatment will be performed.
“c. The risks, complications, and expected benefits or effects of such procedure or treatment.
“d. The risk of not accepting the procedure or treatment.
“e. Any reasonable alternatives to the procedure or treatment and their most likely risks and benefits.
“f. The right to refuse the procedure or treatment.” (American College of Radiology. ACR-SIR Practice Parameter on Informed Consent for Image-Guided Procedures. Resolution 39, 2014; http://bit.ly/1II3ror).
n Make appointments in real time for patients whenever possible.
n Caution (even possible contraindication) the use of this procedure in children. The risk of a “stochastic injury later in life is elevated for pediatric patients who have a longer projected life span and are more radiosensitive in the first decade of life than are adults.” (Pediatr Radiol 2002;32:700.)
Not all procedures are perfect, and many times there are simply not enough data to support their everyday use. Two physicians used a mini C-arm to image foreign bodies in small blinded, randomized control in-vitro study. The physicians used five types of foreign bodies of different densities: metal, gravel, glass, wood, and plastic. The foreign bodies were placed into 50 of the 100 chicken legs. The blinded investigators imaged the legs and determined the presence or absence of foreign bodies. The results showed that although radiographic “imaging located 100 percent of metal, gravel, and glass, plastic and wood could not be consistently detected (sensitivity 0.4, specificity 0.6).” (Pediatric Emerg Care 1997;13:247.) This may conclude that the mini C-arm can detect some foreign bodies but not all. Further clinical trials would help determine whether the procedure is truly necessary.
Foreign body of the foot removed. (Photo by Martha Roberts)
Additional Clinical Pearls
n Unprotected individuals working “24 inches (70 cm) or less from a fluoroscopic beam receive significant amounts of radiation, while those working 36 inches (91.4 cm) or greater from the beam receive an extremely low amount of radiation” (J Ortho Trauma 1997;11:392.)
n Hand and wrist radiation exposure is an identifiable concern because they are uncovered during the procedure. There is little information available on this specific area, but typically the hands do not eagerly absorb radiation.
n Procedures that have been associated with substantial radiation dose: transjugular intrahepatic portosystemic shunt creation, embolization (any location, any lesion), stroke therapy, biliary drainage, visceral angioplasty, stent placement, stent graft placement, chemoembolization, angiography and intervention for gastrointestinal hemorrhage, carotid stent placement, vertebroplasty, radiofrequency cardiac ablation, complex placement of cardiac electrophysiology devices, and percutaneous coronary intervention. (J Vasc Interv Radiol 2003;14:977; J Vasc Interv Radiol 2003;14:711.)
Selfie of the foreign body removal team: Caitlin, RN, Jamie, RN and Martha Roberts, NP. Not pictured: Dr. Kim, and Carol, RN. (Photo by Martha Roberts)
The Final Thought
Jim weighs in: The use of fluoroscopy is an individual choice. Some practitioners are unfamiliar with it, and some hospitals have strict requirements regarding users. The best way to get introduced to the procedure is to watch an orthopedic surgeon or podiatrist do it first. Then, see one, do one, and teach one.
Martha weighs in: Without a doubt, there will be initial push back from your facility concerning your capability to perform this procedure. Talk it out. Your scope of practice allows you to complete this type of intervention with assistance from your radiology team. You have the skills to read and interpret radiographs and remove foreign bodies. The problem is that you need a radiologist and technician to be your ally. Some of the radiology technicians require a radiologist to be at the bedside shooting the continuous fluoroscopy while you do the procedure, and that is just a protocol you need to follow. If this is your house procedure, then do it. There is no reason the radiologist cannot pop over for a five-minute procedure, and help you get set up.
Just have an open and frank conversation about the procedure and why it will be the best for the patient. When you put the patient first, it leaves little room for argument and muscle-flexing. Then again, if your in-house radiology chief flat-out states you cannot perform the procedure, then consider calling podiatry. Finally, if you are pregnant or simply do not want any more radiation exposure than you have already had in this lifetime, consider ultrasound or referral. We can’t all be Superwoman (or man)!