Ultrasound-Guided Percutaneous Removal of Soft-Tissue Foreign Bodies in Children

Abstract

The aim of the study was to determine the effectiveness and complications of ultrasound (US)-guided percutaneous removal of foreign bodies (FBs). Eleven patients were evaluated for US-guided percutaneous removal of FBs in the upper and lower extremities between April 2018 and March 2020 at the pediatric surgery department of a tertiary-level referral hospital. Elongated FBs, without damage to the adjacent neural and vascular tissue, were included. FBs with open wound, those with glass piece, and irregular-shaped and very superficial palpable FBs were excluded.

INTRODUCTION

In children, foreign body (FB) retained in soft tissue is a common cause of consultation, usually due to thorns, wooden splinters, metal, and glass fragments.[1] Approximately 38% of FBs are initially missed, and failure to remove may lead to acute or late complications.[2] Baring very superficial FBs, it can rarely be detected and removed on the basis of clinical examination alone. Imaging techniques are necessary to identify the FB and to determine its exact position before attempting surgical removal. Surgical removal of FBs is invasive, costly, and technically challenging. Ultrasound (US)-guided procedures permit excellent visualization of major anatomic structures adjacent to the impacted FBs.[3]

TECHNIQUE

US-guided percutaneous removal of the FBs was done using a Logiq F6 (GE Healthcare, Chicago, Illinois, USA) imaging device equipped with linear 6–13 MHz probes. After locating the FB, its size, depth, and orientation were documented [Figure 1a]. The relationship between adjacent structures such as muscles, tendons, bone, and vessels was defined. Doppler mode was used where needed. All tasks were carried out by the same team under real-time US guidance. The procedure was done in the operation theater under sedation. Under sterile conditions, the overlying targeted skin area was infiltrated with 2% lidocaine, also injected around and close to the FB under US guidance. A 5 mm-sized skin incision was made at the nearest site from the FB, taking care of important adjacent structures. The incision was made wide enough for the mosquito forceps to be inserted and extraction of the FB. When FBs were located in a deeper part of the soft tissue, a 16G spinal needle was introduced, through which a guidewire (Advin Health Care, India) was inserted [Figure 1b]. After removal of the spinal needle, a tract was developed with serial dilators (6–12 Fr, Advin Health Care, India) over the guidewire for the insertion of mosquito forceps. The arms of the forceps were opened slightly when the tip of the mosquito forceps reached the FB [Figure 1c]. The object was gripped and removed [Figure 1c]. Figure 1d shows the sonography after removal of the object. Figure 2 shows the extracted wooden FB. Antibiotics were administered to all patients for 5 days.

Figure 1.

Ultrasound image. (a) A long foreign body in the soft tissue. (b) A guidewire reaching the foreign body (marked with an arrow). (c) Mosquito forceps grasping the foreign body (marked with an arrow). (d) After completion of the procedure

Figure 2.

Photograph of a removed wooden foreign body

RESULTS

In this study, a cohort of 11 patients underwent US-guided percutaneous removal of FBs. There were eight boys in this study, with a mean age of 9.4 years (range: 5–15 years). The mean interval between trauma onset and US-guided FB removal was 35.6 days (range: 6–84 days). All FBs were visualized as hyperechoic foci on sonograms. In five cases, the agent was a thorn; in three cases, it was a metal; and in three cases, it was a wooden splinter. The chief complaints of the patients were FB sensation in eight (72.8%), pain in seven (63.6%), discharging wound in five (45.4%), abscess formation in two (18.2%), and soft-tissue mass in one (9.1%). In three cases, the FB was located in the upper limbs, six in the lower limbs, and two in the feet. The size of the FB varied between 12 and 34 mm, with a mean of 20.9 mm. The mean time required for the entire procedure was 37 min (range: 25–45 min). There were no intraoperative complications, and the wound healing was uneventful in all patients after removal. The patients were well in the follow-up period.

DISCUSSION

FBs retained in soft tissues after penetrating injuries are likely to seek advice. Adjacent to tendons, it can be a reason for peritendinitis, tenosynovitis, and in or close to the nerves might give posttraumatic neuromas or neuropathies.[1] It can cause allergies, irritation, and infection.[1] They might also migrate to joints, causing arthropathies, or to the venous system, triggering embolic complications.[1]

The condition may be classified into stages,[3] depending on the duration of the injury, as follows: (1) acute: <3 days, (2) intermediate: 3–10 days, and (3) chronic: >10 days. Standard radiographs are widely available, are easy to conduct, and are inexpensive but are not sufficient to visualize radiolucent objects.[2] Computed tomography scans and magnetic resonance imaging are costly and are not used regularly due to poor sensitivity and specificity.[2]

High-frequency (7–17 MHz) US is the first option for soft-tissue FB diagnosis, as it has a sensitivity and specificity of 90% and 96%, respectively.[4] US examination (with color Doppler) also determines the integrity of the surrounding ligaments, tendons, joint capsules, and neurovascular structures. It accurately illustrates the relationship between the FB and the adjacent structures to warrant safe removal of FB, avoiding iatrogenic lesions or complications.[1]

The management of patients with diagnosed or suspected FBs retained in the soft tissues initially requires a distinction between open wounds and small entry-hole wounds. Surgical exploration with an in-depth assessment of lesions is essential in open wounds. If evidence of associated lesions to neurovascular structures or tendons is identified, the open surgical procedure allows repair of the damaged structure and the concurrent search for an FB. Surgical exploration is usually avoided in the case of an FB with a small entry hole because of the objective difficulty of detecting a small FB in the operating field with possible iatrogenic injury. It also requires a long incision, identification of adjacent neurovascular structures, and, to some extent, an unavoidable esthetic impact.

US-guided removal of an FB in soft tissues is a suitable alternative to surgery. It is effective, is inexpensive, and carries a low risk of complications. It leaves a small residual scar with no esthetic effect. Furthermore, failure to remove an FB does not rule out conventional surgical exploration. US-guided technique requires operator experience and good manual skills. In the present case, the construction of a tract using a guidewire and serial dilators was required for safe FB removal. No serious complications occurred during the creation of a tract. The small size of the cohort and short-term follow-up were the limitations of our study.

CONCLUSION

Percutaneous removal of FBs guided by the US is an effective, less invasive, and safe method for extracting FBs in the absence of an open wound and associated lesions requiring surgery.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.