Percutaneous Removal of a Foreign Body From the Distal Phalanx Using a 14 Gauge Needle and Fluoroscopy : Techniques in Orthopaedics

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Percutaneous Removal of a Foreign Body From the Distal Phalanx Using a 14 Gauge Needle and Fluoroscopy

Schwarz, Julia BA; Zhang, Yiyang MD; Dieterich, James MD; Hausman, Michael R. MD

Author Information
doi: 10.1097/BTO.0000000000000588
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The hand is essential in many aspects of daily life, making it particularly vulnerable to injury. One of the more common injuries is foreign bodies, which represent 10% of hand injuries.1 While typically people can remove the foreign body on their own, occasionally they may require surgical attention. Retained foreign bodies can lead to infection, migration, pain, stiffness, and discoloration of the above nail or skin.2

Surgical removal can be time consuming and invasive. Often the dissection and removal can be more morbid than the retained foreign body. Particularly in the case of foreign bodies in the distal phalanx, determining the best approach can be difficult. Both the dorsal and volar approach have significant drawbacks. In a volar approach to the distal phalanx one must transect the pulp and risk damaging a patient’s finger pads, which are critical for sensation. A dorsal approach involves dissecting the nail bed, with longer recovery and risks permanent damage to the germinal or sterile matrices.

We present a patient with a sewing machine needle lodged in her distal phalanx. The needle was broken and completely embedded in bone. No part of the needle was exposed to the skin when she presented. The patient desired foreign body removal because of pain and concern over long-term nail bed changes.

Previous studies have found intraoperative ultrasound as a potential to guide removal of radiolucent foreign bodies in the hand.3 We present a new method of removing a radiopaque foreign body by percutaneously using a 14 gauge needle under fluoroscopy to guide the foreign body out. This offers the advantage of preserving the fingertip in in its near original condition. It allows a patient to maintain a finger that it is aesthetically pleasing, painless, mobile and that can sense pain, temperature, pressure, and fine touch.

TECHNIQUE

Patients who present with a foreign body should first be evaluated with a history to determine the mechanism of injury and the nature of the foreign body itself. A thorough physical exam should be performed to see if the foreign body can be removed in the office and if there are any signs of infection. Radiographs should then be obtained of the foreign body to visualize the location and size. If it is radiopaque and small enough to fit inside a hypodermic needle, the surgeon may consider this percutaneous technique.

The patient is placed supine on the operating table with a hand table attached. A C-arm should be prepped and draped so fluoroscopy can be used during the procedure. A readily available sterile 14 gauge angiocatheter is used for this technique. This was based on evaluation of preoperative x-rays of the foreign body. In addition, multiple angiocatheters were available in the operating room should a different size have been required. The hollow bore is placed through the entrance wound of the foreign body, if visible. An anterioposterior and lateral x-ray should be taken to check that the needle is properly placed so when advanced it will align with the foreign body (Fig. 1A).

F1
FIGURE 1:
Using a 14 gauge hypothermic needle to percutaneously remove the foreign body. A, The needle should be confirmed to be aligned with the foreign body before puncturing the skin. B, The needle is advanced through the phalanx and it is confirmed that it has engulfed the foreign body. C, The needle is pushed out the volar side guiding the foreign body out of the finger.

Once satisfied with the trajectory of the needle in relation to the foreign body, the needle is advanced through the skin using a needle driver, making sure to check it is correctly aligned to capture the foreign body with regular fluoroscopic imaging (Fig. 1B). Once it is confirmed that the needle has engulfed the foreign body, the needle is pushed out though the volar aspect of the finger (Fig. 1C).

For this procedure, it is crucial to choose a needle that is just big enough to engulf the foreign body, yet small enough to engage it and push it out the other side (Fig. 2). After this percutaneous procedure, a band-aid is sufficient for a dressing to cover the needle’s puncture site (Fig. 3).

F2
FIGURE 2:
Image of 14 gauge needle and foreign body.
F3
FIGURE 3:
Image of patient’s finger 2 months postoperatively.

EXPECTED OUTCOMES

This procedure offers many advantages over a traditional open incision of the distal phalanx to remove a foreign body. The finger’s volar surface are covered with glabrous skin containing a high density of several specialized nerve endings: Meisnner’s corpuscles and Merkel discs for light touch, Pacinian corpuscles for vibration and pressure, free nerve endings for temperature and pain, and Ruffini endings for skin stretch. These receptors allow fingers to sense the world, relaying crucial information, that make them so useful in moving through daily life. This is also why fingers are at high risk for a foreign body to become lodged in them. The percutaneous technique presented here offers the advantage of almost completely sparing the glabrous skin of the fingertip. The patient will only have a minor needle puncture.

To the authors knowledge, this technique has never been described before for upper extremity foreign bodies. On review of the literature, 1 report by Siciliano and Lefkowitz4 described using a trephine to remove a foreign body under fluoroscopic guidance in a calcaneus.

Another advantage of this technique is the ability to preserve the nail. Management of nail injuries can be a challenging experience. If the foreign body is to be removed dorsally it is likely that the nail would need to be partially or fully removed. Potential injuries to the germinal and/or sterile matrix may be unavoidable. Nail bed healing and nail plate regrowth is slow and can be difficult to predict.5 Therefore, the fingertip must be monitored for a duration of time before the final outcome can be known. Patients can develop a split nail deformity or when excessive bone is removed from the distal phalanx, a parrot beak deformity. A scar on the germinal matrix impairs germinal nail production, leaving an empty longitudinal area of nail between 2 normal regions. A parrot beak deformity involves the deformed nail growing over the tip in a curved manner. This can cause severe pain and interfere with function. Finally, the quick recovery time of this procedure is a significant advantage allowing patients to get back to their daily activities immediately, reducing discomfort and minimizing time missed at work.

COMPLICATIONS

Potential downsides of the procedure is the increased use of radiation in comparison to an open procedure. In addition, all foreign bodies may not be conducive to this procedure depending on their shape and where in the finger they are lodged. Finally, this specific technique may be more difficult with radiolucent foreign objects although future work could look at trying this technique using ultrasound technology.

REFERENCES

1. Hollander JE, Singer AJ, Valentine S, et al. Wound registry: development and validation. Ann Emerg Med. 1995;25:675–685.
2. Lammers RL. Soft tissue foreign bodies. Ann Emerg Med. 1988;17:1336–1347.
3. Huttin C, Diaz JJH, Vernet P, et al. Relevance of intraoperative ultrasound imaging for detecting foreign bodies in the hand: a series of 19 cases. Hand Surg Rehabil. 2018;37:363–367.
4. Siciliano CJ, Lefkowitz H. Removal of an intraosseous metallic foreign body in the calcaneus utilizing a fluoroscopically guided bone trephine. J Foot Ankle Surg. 1994;33:83–86.
5. George A, Alexander R, Manju C. Management of nail bed injuries associated with fingertip injuries. Indian J Orthop. 2017;51:709–713.
Keywords:

distal phalanx; foreign body; novel technique; percutaneous approach

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