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10.14 Needle (Foreign Body) in Foot


Presentation

Although a needle could be embedded under any skin surface, most commonly a patient will have stepped on one while running or sliding barefoot on a carpeted floor. Generally, but not invariably, the patient will complain of a foreign body sensation with weight bearing. A very small puncture wound will be found at the point of entry, and, on occasion, a portion of the needle will be palpable.

What to do:

What not to do:

Discussion:

Many a young doctor has been found sweating away at the foot of an emergency department stretcher, unable to locate a needle foreign body. The secret for improving your chances of success is in realizing that the x ray only gives you an approximate location of the needle and that your incision must be made in a direction and location best suited for locating the needle, not removing it.

There are three additional principles to keep in mind. First, the roentgenographic position of the needle must be correlated with the anatomy of the skin surface rather than the bony anatomy of the foot. Second is the simple geometric principle that the surest way to interesct a line (the needle) is to dissect in the plane perpendicular to its midpoint. Third, the only structures of importance in the forefoot or heel that lie plantar to the bones are the flexor tendons and they lie close to the bones.

When you let the patient know how difficult it sometimes is to locate the needle and remove it, you place yourself in a win-win situation. You look especially good if you find it and you still look experienced and well-informed if you don't.

If you choose to take the patient to fluoroscopy, you or the radiologist can place a hemostat around the needle under direct vision. It can then be pushed out using the same technique described above.

Linear foreign bodies such as needles can be removed from the sole of the foot without extensive dissection, complex apparatus or repeated roentgenographic studies. Although blind dissection is generally not a good technique because of the risk of injury, in this particular situation, relative safety can be provided by gentle dissection with iris scissors of insufficient strength to sever tendons, and by setting firm limits of time and depth of exploration.

References:


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Craig Feied, MD
Mark Smith, MD
Jon Handler, MD
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