What is the best course of treatment for a 12-year-old female patient with pencil lead and wood stuck in her buttocks near the rectum?

Management of Pencil Lead and Wood Foreign Body in Buttock Near Rectum

For a 12-year-old female with pencil lead and wood embedded in the buttock near the rectum, immediate bedside removal under appropriate anesthesia is the first-line approach if the foreign body is superficial and accessible, followed by wound exploration to ensure complete removal and assessment for deeper penetration or rectal involvement. 1

Initial Assessment and Imaging

Clinical Evaluation

• Perform careful external examination to determine the depth of penetration, proximity to the anal verge, and presence of any systemic signs of infection (fever, tachycardia, hemodynamic instability). 1
• Assess for signs of rectal perforation: severe pain, inability to sit, rectal bleeding, or signs of peritonitis. 1
• Digital rectal examination should be deferred until imaging is obtained if there is concern for deep penetration or rectal involvement, as manipulation could worsen injury. 2

Imaging Strategy

• Obtain plain radiographs first (anteroposterior and lateral views of the pelvis/buttock) to identify radiopaque components (graphite appears moderately radiopaque, wood may not be visible). 1, 2
• CT scan without contrast is essential if plain films are negative but clinical suspicion remains high, as wood and pencil fragments have false-negative rates up to 85% on plain radiography but appear moderately hyperdense on CT. 2, 3
• CT provides critical information: exact location, depth of penetration, proximity to rectum, presence of abscess formation, subcutaneous emphysema, or bowel perforation. 1, 3

Treatment Approach

For Superficial Buttock Foreign Bodies (No Rectal Involvement)

• Attempt bedside removal under local anesthesia with adequate anxiolysis/sedation appropriate for a 12-year-old, ensuring complete extraction of all fragments including wood splinters. 1
• Thorough wound exploration and irrigation is mandatory, as retained wood fragments can lead to chronic infection or abscess formation. 1
• Antibiotics are NOT routinely indicated for simple superficial foreign body removal without signs of infection or significant cellulitis. 1

For Deep Penetration or Suspected Rectal Involvement

• If the foreign body has penetrated the perianal/perirectal region, this becomes a complex abscess scenario requiring surgical drainage under general anesthesia. 1
• Empiric broad-spectrum antibiotics covering Gram-positive, Gram-negative, and anaerobic bacteria are indicated if there is significant cellulitis, systemic signs of infection, or concern for rectal involvement. 1
• Surgical exploration under general anesthesia allows complete muscle relaxation, adequate visualization, removal of all foreign material, and assessment for occult rectal perforation. 1

If Rectal Perforation is Confirmed

• Small, fresh perforation with minimal contamination: primary repair after foreign body removal if tissues are healthy and well-vascularized. 1
• Larger perforation or significant contamination: surgical consultation for potential diversion, though this is unlikely in a healthy 12-year-old with prompt presentation. 1
• Post-removal proctoscopy or flexible sigmoidoscopy should be performed to evaluate bowel wall integrity if there was any concern for rectal involvement. 1

Special Considerations for Pediatric Patients

Consent and Confidentiality

• Emergency treatment can proceed without parental consent if the condition is urgent and the parent/guardian is not immediately available, as appropriate medical care should never be delayed. 4
• However, every effort should be made to contact parents/guardians and obtain consent, documenting all attempts. 4, 5
• Given the location and mechanism of injury, consider non-accidental trauma or sexual abuse in the differential diagnosis, particularly if the history is inconsistent or vague. 6
• Mandatory reporting to child protective services may be required depending on the circumstances and your jurisdiction's laws. 6

Anesthesia Considerations

• For superficial removal: local anesthesia with lidocaine plus procedural sedation (midazolam, ketamine, or nitrous oxide) is appropriate. 1
• For deeper exploration or rectal involvement: general anesthesia in the operating room provides optimal conditions for complete removal and assessment. 1

Post-Removal Care

• Wound care: Leave wound open to heal by secondary intention if contaminated; primary closure only if clean and superficial. 1
• Tetanus prophylaxis: Update if not current (Tdap preferred in adolescents). 1
• Follow-up imaging is NOT routinely required unless there is recurrence, non-healing wound, or persistent symptoms suggesting retained foreign material. 1
• Close follow-up in 24-48 hours to assess for signs of infection, abscess formation, or retained foreign body. 1

Common Pitfalls to Avoid

• Do not assume complete removal based on external appearance alone—wood splinters are notorious for fragmenting and being retained. 2, 3
• Do not skip CT imaging if plain films are negative but clinical suspicion for deep penetration or rectal involvement exists. 2, 3
• Do not perform aggressive digital rectal examination before imaging if deep penetration is suspected, as this could worsen occult perforation. 1
• Do not give routine antibiotics for simple superficial foreign bodies—reserve for complex cases with cellulitis, systemic signs, or rectal involvement. 1
• Do not miss the possibility of non-accidental trauma—maintain high index of suspicion and follow mandatory reporting laws. 6