Ekstremite yerleşimli yabancı cisimlerin görüntülenmesinde ve cerrahi tedavide

Öz

Amaç: Bu çalışmada yabancı cisim batması olan olgularda tanı ve tedavideki zorlukları ve bu konuda dikkat edilmesi gereken noktaları değerlendirmeyi amaçladık. Çalışma planı: Şubat 2005 ve Temmuz 2011 tarihleri arasında yabancı cisim batması nedeniyle ameliyat edilen 295 olgu (150 erkek, 145 kadın; ortalama yaş 26.82±16.84; dağılım: 3-79) geriye yönelik olarak incelendi. Etkilenen taraf, yabancı cismin türü, lokalizasyonu, şikayetler, görüntülemede hangi tekniğin tercih edildiği, yaralanmanın olduğu mevsim, yabancı cismin vücuttaki etkileri, yaralanma ile cerrahi müdahale arasında geçen süre, çıkarma endikasyonu, anestezi tipi, cerrahi tedavi esnasında skopi kullanımı ile cerrahi girişimin komplikasyonları değerlendirildi. Bulgular: Yabancı cismin 157 olguda sağ, 138 olguda ise sol ekstremitede olduğu görüldü. Dört olguda dirsekte, 6 olguda ön kolda, 6 olguda el bileğinde, 75 olguda elde, 1 olguda kalçada, 7 olguda uylukta, 11 olguda diz çevresinde, 6 olguda diz ekleminde, 10 olguda kruriste, 8 olguda ayak bileğinde ve 161 olguda ise ayak tabanındaydı. Yaralanma dönemi 148 olguda yaz, 107 olguda kış, 35 olguda ilkbahar ve 5 olguda sonbahar mevsimi olarak belirlendi. Ekstremitelerden 216 iğne, 33 metal, 28 cam, 10 tahta, 4 plastik, 4 taş parçası çıkartıldı. Yaralanma ile operasyon arasında geçen süre 135 olguda 1, 114 olguda 2-10, 22 olguda 11-30, 13 olguda 30-365 gün iken, 11 olguda çıkartma işlemi 365 gün sonrasında gerçekleştirildi. Çıkarımlar: Yabancı cisim batması, enfeksiyon, migrasyon, eklemlerde hareket kısıtlılığı gibi çeşitli komplikasyonlarla sonuçlanabilir. Ayrıntılı anamnezle birlikte fizik ve radyolojik muayeneler, bu hastaların tedavilerinden en iyi sonuç alınması yönünden son derece önem taşımaktadır.

Anahtar Kelimeler

• Çıkartma; ekstraksiyon; ekstremiteler; yabancı cisimler.

Tips and tricks in the diagnostic workup and the removal of foreign bodies in extremities

Abstract

Objective: The aim of this study was to analyze the diagnostic and therapeutic challenges during the removal of foreign bodies in extremities, and to provide relevant tips and tricks.
Methods: The medical records of 295 patients (150 men, 145 women; mean 26.82±16.84 years; range: 3 to 79 years) who underwent foreign body removal from their limbs between February 2005 and July 2011, were retrospectively reviewed. Side of the extremity, foreign body type, location, complaints, imaging technique, the season of injury, the effects of foreign body in the body, the time between injury and extraction, indication forextraction, type of anesthesia, the use of fluoroscopy during the surgical procedure, and complications of surgical intervention were analyzed.
Results: The injury was in the right limb in 157 patients and in the left limb in 138 patients. Foreign bodies were in the elbow in 4 cases, in the forearm in 6, in the wrist in 6, in the hand in 75, in the hip in 1, in the thigh in 7, around the knee joint in 11, in the knee joint in 6, in the lower leg in 10, in the ankle in 8, and in the foot sole in 161. The season of injury was summer in 148 cases, winter in 107, spring in 35, and autumn in 5. The removed foreign bodies were needles in 216 cases, metallic objects in 33, pieces of glasses in 28, pieces of wood in 10, pieces of plastic in 4, and pieces of stone in 4. The time between the injury and foreign body removal was 1 day in 135 cases, 2 to 10 days in 114, 11 to 30 days in 22, and 30 to 365 days in 13. The removal time was longer than 1 year such in 11 cases.
Conclusion: Foreign body injuries may result in serious complications such as infection, migration and joint stiffness. A throughout history and physical and radiological examinations are of tremendous importance to achieve the best outcome in these patients. 

Keywords

• Extraction
• foreign bodies
• limbs
• extraction
• removal

Kaynakça

1. Hunter TB, Taljanovic MS. Foreign bodies. Radiographics 2003;23:731-57.
2. Courter BJ. Radiographic screening for glass foreign bodies- -what does a “negative” foreign body series really mean? Ann Emerg Med1990;19:997-1000.
3. Sidharthan S, Mbako AN. Pitfalls in diagnosis and problems in extraction of retained wooden foreign bodies in the foot. Foot Ankle Surg 2010;16:e18-20.
4. Rubin G, Chezar A, Raz R, Rozen N. Nail puncture wound through a rubber-soled shoe: a retrospective study of 96 adult patients. J Foot Ankle Surg 2010;49:421-5.
5. Flom LL, Ellis GL. Radiologic evaluation of foreign bodies. Emerg Med Clin North Am 1992;10:163-77.
6. Orlinsky M, Bright AA. The utility of routine x-rays in all glass-caused wounds. Am J Emerg Med 2006;24:233-6.
7. Coombs CJ, Mutimer KL, Slattery PG, Wise AG. Hide and seek: pre-operative ultrasonic localization of non radio- opaque foreign bodies. Aust N Z J Surg 1990;60:989-91.
8. Shiels WE, Babcock DS, Wilson JL, Burch RA. Localization and guided removal of soft-tissue foreign bodies with sonog- raphy. AJR Am J Roenigetiol 1990;155:1277-81.

9. Bauer AR Jr, Yutani D. Computed tomographic localization of wooden foreign bodies in children’s extremities. Arch Surg 1983;118:1084-6.
10. Monu JU, McManus CM, Ward WG, Haygood TM, Pope TL, Bohrer SP. Soft-tissue masses caused by long-standing foreign bodies in the extremities: mr imaging findings. AJR Am J Roentgenol 1995;165:395-7
11. Peterson JJ, Bancroft LW, Kransdorf MJ. Wooden foreign bodies: imaging appearance. AJR 2002;178:557-62.
12. Pattamapaspong N, Srisuwan T, Sivasomboon C, Nasuto M, Suwannahoy P, Settakorn J, et al. Accuracy of radiography, computed tomography and magnetic resonance imaging in diagnosing foreign bodies in the foot. Radiol Med 2013;118: 303-10.
13. Gaughen JR, Keats TE. Soft tissue calcifications in the lower extremities of severely diabetic patients simulating venous stasis or collagen vascular disease. Emerg Radiol 2006; 13:135-8.
14. Bode KS, Haggerty CJ, Krause J. Latent foreign body syn- ovitis. J Foot Ankle Surg 2007; 46:291-6.
15. McGuckin JF, Akhtar N, Ho VT, Smergel EM, Kubacki EJ, Villafana T. CT and MR evaluation of a wooden foreign body in an in vitro model of the orbit. AJNR 1996;17:129-33.
16. Teitelbaum GP, Yee CA, Van Horn DD, Kirn HS, Colleth PM. Metallic ballistic fragments: MR imaging safety and artifacts. Radiology 1990;175:855-9.
17. Salati SA, Rather A. Missed foreign bodies in the hand: an experience from a center in Kashmir. Libyan J Med 2010;12: 5.
18. Nagendran T. Management of foreign bodies in the emer- gency department. Hospital Physician 1999:9;27-40.
19. Vargas B, Wildhaber B, La Scala G. Late migration of a for- eign body in the foot 5 years after initial trauma. Pediatr Emerg Care 2011;27:535-6.
20. Gregory B, Anvesh Roy, Paul J. Moroz, Firth. Foreign body migration along a tendon sheath in the lower extremity: a case report and literature review. J Bone Joint Surg Am 2011; 20;93:e38.
21. Bu J, Overgaard KA, Viegas SF. Distal migration of a foreign body (sago palm thorn fragment) within the long-finger flex- or tendon sheath. Am J Orthop (Belle Mead NJ) 2008;37: 208-9.
22. Ginsberg LE, Williams DW, Mathews VP. CT in penetrat- ing craniocervical injury by wooden foreign bodies: reminder of a pitfall. AJNR Am J Neuroradiol 1993;14:892-5.
23. Wood GW. Open fractures caused by firearm. In: Canale ST, Beaty JH, editors. General principles of fracture treat- ment. Vol. 3, 11th ed. Philadelphia: Elsevier; 2008. p. 3024.
24. Kenneth JK. Gunshot wounds and open fractures. In: Lieberman JR, editor. Comprehensive orthopaedic Rreview. Section 6, 1st ed. Rosemont: AAOS; 2009. p. 534.
25. Sharma S, Azzopardi T. A simple surgical technique for removal of radio-opaque foreign objects from the plantar surface of the foot. Ann R Coll Surg Engl 2006;88:76.
26. Mardel SN. Removal of foreign bodies from the foot, a tech- nique using high elevation and local anaesthesia. Arch Emerg Med 1990;7;111-3.
27. Leung A, Patton A, Navoy J, Cummings RJ. Intraoperative sonography-guided removal of radiolucent foreign bodies. J Pediatr Orthop 1998;18:259-61.
28. Mahirogullari M, Cilli F, Akmaz I, Pehlivan O, Kiral A. Acute arthroscopic removal of a bullet from the shoulder. Arthroscopy 2007;23:676.e1-3.
29. Lamb DW, Kuczynski K. Foreign bodies in the hand. In: Lamb DW, Kuczynski K, editors. The practice of hand sur- gery. 1st ed. Oxford: Blackwell Scientific Publications; 1981. p. 486.
30. Humzah D, Moss AL. Delayed digital nerve transection as a result of a retained foreign body. J Accid and Emerg Med 1994;11;261-2.
31. Dürr HR, Stäbler A, Müller PE, Refior HJ. Thorn-induced pseudotumor of the metatarsal.A case report. J Bone Joint Surg Am 2001;83:580-5.
32. Wegener B, Ficklscherer A, Muller PE, Baur-Melnyk A, Jansson V, Durr HR. Toothpick injury simulating a pig- mented villonodular synovialitis. J Pediatr Surg 2009;44:e29- 32
33. Markiewitz AD, Karns DJ, Brooks PJ. Late infections of the foot due to incomplete removal of foreign bodies: a report of two cases. Foot Ankle Int 1994;15:52-5.
34. Siegel IM. Identification of non-metallic foreign bodies in soft tissue: Eikenella corrodens metatarsal osteomyelitis due to a retained toothpick. A case report. J Bone Joint Surg Am 1992;74:1408-10
35. Laor T, Barnewolt CE. Nonradiopaque penetrating foreign body: “a sticky situation". Pediatr Radiol 1999;29:702-74.
36. Sönmez MM, Seçkin FM, Sen B, Birgen N, Ertan A, Oztürk I. A review of malpractice claims concerning orthopedic applications submitted to the Council of Forensic Medicine. Acta Orthop Traumatol Turc 2009;43:351-8
37. Vukmir RB. Medical malpractice: managing the risk. Med Law 2004;23:495-513.
38. Karcz A, Korn R, Burke MC, Caggiano R, Doyle MJ, Erdos MJ, et al. Malpractice claims against emergency physicians in Massachusetts: 1975-1993. Am J Emerg Med 1996;14:341-5.
39. Kaiser CW, Slowick T, Spurling KP, Friedman S. Retained foreign bodies. J Trauma 1997;43:107-11.