The postoperative radiograph showed no sign of a foreign body.
The hand is the most common site for foreign body injuries. Glass, wood, and metal are the most common materials. Pencil lead injuries often occur in school-age children, frequently in the head and neck region.[3,4]
Patients with a suspected retained foreign body in the hand present with pain, localized swelling, or sometimes no symptoms at all. In the absence of symptoms, clinical signs, and adequate imaging studies, insufficient clinical history and failure to perform precise exploration can lead to a missed diagnosis and a retained foreign body. One study reported that 4.7% of 950 tendons retrieved at autopsy had silent foreign bodies. Another study reported that 38% of retained foreign bodies in the hand were missed by the first treating physician. The patient in this case also presented with no symptoms, and there was no sign of inflammation during the exploration.
Retained foreign bodies can be inert, or can result in both acute and chronic complications, including infection, nerve apraxia or injury, nail deformity, fracture, inclusion cyst, tendonitis, tenosynovitis, adhesion, and migration of the foreign body.[2,5] Foreign bodies may move to adjacent tissues, but rarely wander far. Migrations into major blood vessels, and abdominal, thoracic, and cranial cavities, have been reported.[6–10] Several reports describe foreign body migration, usually in the upper extremities but also in the lower extremities.[5,11–14] Among these cases, those reported by Firth et al and Bu et al are similar to the present case by showing that the direction of migration is associated with the shape of the foreign body.[12,13] All were characterized by a sharp, pointed end (toothpick and sago palm leaf thorn), which facilitated directional movement. Identifying the shape of the foreign body may predict the orientation and probability of movement. Further, a surgeon must consider surgical removal if the object is near a tendon or vessel, considering the possibility of an unexpected journey, even if the retained foreign body is inert.
Pencil leads are composed of graphite, kaolinite, wax, or other animal fat. A chemical or biologic reaction induced by the pencil lead itself may be trivial. A pencil lead in the eyeball can be inactive and cause no inflammation for a long time, even for over a decade.[16,17] However, as far as we know, potential toxicity of the pencil lead has not been fully investigated. In this case, there was no intraoperative sign of inflammation or foreign body reaction.
Unlike metal or glass, a pencil lead is visualized by only 50% of radiographic studies. The pencil lead was invisible in this patient's initial radiograph, but appeared in later studies taken at our hospital. This may reflect different radiation doses in taking X-rays. In a study on foreign bodies in the maxillofacial region, CT was best for the identification of graphite. We also performed CT, and clearly recognized the foreign body, as well as its shape, size, and 3-dimensional position relative to adjacent structures. Ultrasonography is an inexpensive, radiation-free tool, and is highly sensitive for identification of superficial foreign bodies. However, the pencil lead in this case was located deep beneath the flexor tendon, and could not be detected with ultrasonography. Magnetic resonance imaging (MRI) is an option, but is expensive. Moreover, graphite in the pencil lead has diamagnetic properties; lacking intrinsic magnetism, it will weaken a local magnetic field, and eventually leave a susceptibility artifact on the image. Two cases of blooming artifact on MRI due to pencil lead have been reported.[19,20]
Adequate clinical history and appropriate imaging will aid in diagnosis of a foreign body and guide the treatment plan. As history-taking in children is problematic, objective results are vital. In diagnosing pencil lead penetration, CT is the most useful tool. The choice of surgical intervention and treatment requires consideration of the foreign body configuration, relationship with adjacent structures, and possibility of complications including local or distant migration.
Conceptualization: Jae Ha Hwang.
Supervision: Kwang Seog Kim, Sam Yong Lee.
Writing – original draft: Jae Ha Hwang, Dong Gyu Lee.
Writing – review & editing: Jae Ha Hwang.
Jae Ha Hwang 0000-0001-6992-8067.
Dong Gyu Lee 0000-0003-3701-0395.
Kwang Seog Kim 0000-0002-6766-4640.
Sam Yong Lee 0000-0002-3185-2519.
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Keywords:Copyright © 2019 The Authors. Published by Wolters Kluwer Health, Inc. All rights reserved.
foreign body; hand; tendon