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April 2008
By Phillips Perera, MD, RMDS, and Diku Mandavia, MD, FACEP, FRCPC
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Presentation:
A 40-year-old man presents to your emergency department complaining of a large wood splinter in his left hand. The injury occurred three hours ago while he was working at a construction site. The patient has localized pain in his palm.
Physical examination reveals a small entry wound in the thenar eminence of his left hand but no palpable foreign body. The area is mildly tender but without signs of infection. Both neurovascular and tendon exams of the hand are normal. His plain radiograph shows no abnormalities. How can bedside sonography help you treat this patient?
Click for diagnosis and discussion |
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Diagnosis and discussion:
This case demonstrates the challenges inherent in foreign bodies. While radiopaque foreign bodies such as metal or glass can easily be found with radiographs or fluoroscopy, radiolucent materials like wood, thorns, or plastic are essentially invisible. Magnetic resonance imaging is a useful tool for locating these substances, but it remains unavailable to most emergency physicians.
In these cases, a high-frequency linear array transducer should be used to scan multiple planes around the area where the patient feels the foreign body. The adjacent ultrasound image shows a nonanatomic hyperechoic line representing the large, wooden foreign body embedded in the patient’s hand. Because of the depth of the splinter within the palm, a surgeon was consulted. He operated on the hand, guided by the ultrasound image from the emergency department, and successfully removed the splinter. |
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Dr. Perera is an assistant clinical professor of emergency medicine at Columbia University College of Physicians and Surgeons and Weill Cornell Medical College and director of emergency ultrasound at New York Presbyterian Hospital in New York City. Dr. Mandavia is a clinical associate professor of emergency medicine and director of emergency ultrasound at Los Angeles County-USC Medical Center and an attending staff physician at Cedars-Sinai Medical Center in Los Angeles.
Emerg Med 40(4):25-6, 2008
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