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11.06 Superficial Sliver


Presentation

The patient has caught himself on a sharp splinter (usually wooden) and either cannot grasp it, has broken it trying to remove it, or has found it is too large and painful to remove. The history may be somewhat obscure. On examination, you should find a puncture wound with a tightly embedded sliver that may or may not be palpable over its entire length. There may only be a puncture wound without a clearly visible or palpable foreign body.

What to do:

What not to do:

Discussion

The most common error in the management of soft tissue foreign bodies is failure to detect their presence. An organic foreign body is almost certain to create an inflammatory response and become infected if any part of it is left beneath the skin. It is for this reason, along with the fact that wooden slivers tend to be friable and may break apart during removal, that complete exposure is generally necessary before the sliver can be taken out. Of course, very small and superficial slivers can be removed by loosening them and picking them out with a #18 gauge needle, avoiding the more elaborate technique described above. When only the outer skin layers are involved, reassuring the patient and gently manipulating the wound can usually obviate the need for anesthesia.

If the foreign body cannot be located, explain to the patient that you do not want to do any harm by exploring and excising any further, and that therefore, you will let the splinter become infected so it will "fester" and form a "pus pocket," when it can be more easily removed. If this procedure is followed, it should always be coordinated with a followup surgeon. The patient should be placed on an antibiotic and provided with followup care within 48 hours.

When making an incision over a foreign body, always take the underlying anatomical structures into consideration. Never make an incision if there is any chance that you may sever a neurovascular bundle, tendon, or other important structure.

When a patient returns after being treated for a puncture wound and there is evidence of non-healing or recurrent exacerbations of inflammation, infection or drainage, assume that the wound still contains a foreign body and refer him for surgical consultation.


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from Buttaravoli & Stair: COMMON SIMPLE EMERGENCIES
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