What medical specialty should be consulted for foreign bodies in the soft tissue of the hand?

Management of Foreign Bodies in the Soft Tissue of the Hand

Hand surgeons should be consulted for the evaluation and removal of foreign bodies in the soft tissue of the hand, as they have specialized expertise in hand anatomy and can best manage potential complications affecting tendons, nerves, and vascular structures. 1

Diagnostic Approach

Initial Evaluation

• Radiographs of the area of interest are the appropriate first imaging study for suspected foreign bodies in the hand or wrist 1
• Plain radiographs should include multiple views to maximize detection of radiopaque foreign bodies 2
• However, many foreign bodies (especially wood, plastic, and other organic materials) are radiolucent and not visible on standard radiographs 2, 3

Secondary Imaging When Radiographs Are Negative

• Ultrasound (US) is the preferred imaging modality when radiographs are negative but foreign body is still suspected 1

  • US has reported sensitivity of 95% for foreign body detection 1
  • All foreign bodies appear hyperechoic on US with some degree of posterior acoustic shadowing 1
  • US can characterize foreign body morphology, depth, and relationship to adjacent structures 1

• CT without IV contrast is an equivalent alternative to US 1

  • CT has high sensitivity for detection of radiopaque foreign bodies 1
  • CT is superior to MRI for identifying water-rich fresh wood 1
  • CT is recommended when foreign bodies penetrate into deep tissues or bone 1

Limitations of Different Imaging Modalities

• Ultrasound limitations:

  • Reduced effectiveness for foreign bodies deeper than 4cm from skin 1
  • Difficult visualization if air is present in adjacent soft tissues 1
  • Cannot detect foreign bodies within bone 1

• MRI limitations:

  • Lower sensitivity compared to CT and US for foreign body detection 1
  • Potential risk with metallic foreign bodies due to magnetic field interaction 1
  • Radiographic screening for metallic foreign bodies is recommended before MRI 1

Management Considerations

Surgical Consultation

• Hand surgeons should be consulted due to:
  • Complex anatomy of the hand with closely packed neurovascular structures 4, 5
  • Risk of damage to tendons, nerves, and blood vessels during removal 1
  • Potential for infection, inflammation, and functional impairment if not properly managed 4

Removal Techniques

• US-guided removal can be considered as a first-line treatment procedure 5

  • Allows real-time visualization during the procedure 5
  • Can be performed through a small incision 5
  • Effectiveness approaching 100% in appropriate cases 5

• Surgical exploration is necessary when:

  • Foreign body is adjacent to critical structures 1
  • There is evidence of infection or abscess formation 4
  • Foreign body is embedded in bone 1

Complications to Monitor

• Chronic inflammation and infection can develop even months after the initial injury 4, 3
• Granuloma formation may occur around retained foreign bodies 4
• Tendon or nerve injury may result from the foreign body or during removal 1

Important Clinical Pearls

• Foreign bodies should be suspected in any hand injury, particularly with appropriate history 2
• Patients with symptoms of cellulitis, osteomyelitis, or palpable mass in the hand for over a month should be evaluated for retained foreign bodies 4
• Some patients may not recall the initial injury, especially with delayed presentations 4, 3
• Wooden splinters and other organic materials can cause significant inflammatory reactions and abscess formation if not completely removed 3, 6