A wide variety of foreign bodies are implanted on their own or injected into the skin. These items are most often contaminated, and therefore puncture wounds to the skin should in most cases be considered infected. Therefore, it is necessary to prescribe, guided by the size of the wound and the degree of its contamination. Tetanus prophylaxis is also carried out, determined by the nature of previously received vaccinations.
The question often arises - to remove or not to remove a foreign body of the skin? As a rule, if a little time has passed after the injury and the foreign body of the skin is clearly defined, it must be removed. On the other hand, in the absence of symptoms, the risk of removal outweighs the risk of finding a foreign body, and therefore it is best to leave it in place. In any case, the solution to this sometimes difficult issue depends on the nature of the foreign body and its localization.
Diagnosis is usually based on history. A conventional x-ray does not reveal all skin foreign bodies. Electroradiography and soft tissue radiography can be of great help in detecting glass, plastic objects and wood chips. Study in transmitted light (transillumination) of small colors of the body, such as fingers, hand, leg, hand, foot, also helps to determine the presence and localization of chips and splinters. In cases where a foreign body is located deep in the muscles or in the subcutaneous fat, the study must necessarily be carried out in two projections, regardless of which method is used.
If only a foreign body of the skin is not completely superficial, then it is most effective and least traumatic to remove it under general anesthesia. When manipulating the hand and foot, a regional blockade can be applied. Local infiltration with anesthetics should, however, be avoided, as it leads to swelling, sometimes slight bleeding, and some tissue displacement, which can complicate an already difficult task. Small, short pointed objects such as needles are especially difficult to remove, as they easily move and migrate deeper during surgery. It is much easier and more expedient to remove them using general anesthesia and performing the intervention under the control of a screen in the operating room. The incision should be small. A clamp is inserted through it, directing it directly to the needle, which is grasped and, carefully maneuvering, is removed.
Woody foreign bodies of the skin
The tree is almost always contaminated, and therefore, in order to prevent infection, its pieces trapped in soft tissues must be removed. Soreness and flushing of the skin is usually noted around the inlet. If the chip is visible, a local anesthetic can be used and removed by grasping it with a forceps or by excising the tissue through a small incision directly above it. Deeply located chips or remnants of partially removed foreign bodies must first of all be clearly localized using xero- or soft-tissue radiography. In the presence of multiple small pieces, it is more rational not to search for each one, but to excise the wound canal and all affected soft tissues containing foreign bodies, if localization allows this. Splinters under the toenails or toenails should be removed by wedge-shaped excision of the nail covering the foreign body. This converts the anaerobic wound into an aerobic one and, in addition, the entire fragment can be removed without difficulty with this method.
Metallic foreign bodies of the skin
Metal shards are usually smaller than wood chips and cause less severe reactions. They are especially difficult to detect as they can penetrate deep into soft tissue. Radiography almost always reveals metallic foreign bodies. If they are not clearly defined, then they should not be deleted.
Needles or parts of needles, if localized in soft tissue in the palm or foot, can be very troublesome. They enter through a small wound and are able to penetrate deeply, migrating with any movement. If an X-ray foreign body is detected, the limb should be immobilized immediately. Successful removal requires general anesthesia, the application of a tourniquet, which allows manipulation without blood, and the ability to use an X-ray screen, as described above.
Sometimes an injection needle that has broken during medical manipulation remains in the soft tissues. These needles are usually sterile and do not need to be removed urgently unless it is not difficult to remove them or when the patient has any symptoms.
If the needle broken off during lumbar puncture remains in the spine, then after X-ray control, an operation is performed, which may not only be long-term, but sometimes even require removal of the vertebral arch or spinous process.
Fishing hooks are usually embedded in the fingers or palm. Their teeth make it very difficult to remove. A fish hook can be removed without much difficulty by pushing it forward with the sharp tip, poking it through the skin, and cutting off the barb.
Pieces of glass are often embedded in the hand or foot. In some cases, small fragments splashed on the face or body can be removed with an adhesive patch. Xeroentgenography usually reveals only large pieces of glass in soft tissues. However, they are extremely difficult to detect during surgery. And since they are usually accompanied by minimal inflammation, they are removed later if persistent signs of infection appear.
The article was prepared and edited by: surgeonIt is a benign thickening, which is an overgrowth of fibrous tissue on the foot in the area of the plantar nerve of the foot. This disease is referred to as Morton's syndrome, Morton's disease, interdigital neuroma, foot neuroma, perineural fibrosis, and Morton's toe syndrome.
A pathological neoplasm develops mainly in the area of the third intermetatarsal space (the area of the base between the third and fourth toes on the foot). Basically, one-sided lesion of the nerve is found, but two-sided is extremely rare. Morton's neuroma occurs most often in women of fifty years of age.
Causes of occurrence
- Mechanical factor - arises from the compression of the nerve by the bones of the metatarsus, which pass between the third and fourth fingers;
- Transverse flat feet - this ailment puts constant pressure on the nerve;
- Acute injuries, hematomas, obliterating diseases of the legs, as well as chronic infections;
- Significant overloading of the forefoot and prolonged standing;
- Wearing tight shoes that cause pain and discomfort when walking, which causes pressure on the nerve;
- Overweight - a large body weight puts pressure on the nerve tissue of the lower extremities.
There are many reasons why a foot nerve disease can develop. Such factors lead to irritation of nerve fibers, which change their structure over time, which in most cases leads to inflammatory processes.
Symptoms and first signs
The initial stage of the disease may not be visually noticeable, that is, upon examination, even an experienced specialist can make an erroneous conclusion. The main sign of the presence of a pathological process is pain when the area between the fingers is compressed in the transverse direction.
Patient complaints are mainly as follows:
- Numbness in the toes
- Aching pains and burning;
- Discomfort and tingling;
- Sensation of a foreign body in the area of localization of the disease.
The symptomatology of the disease is mild and may subside for a while, sometimes the lull lasts for several years. Exacerbations of the neuroma occur during the period of wearing narrow or tight shoes, as well as high-heeled shoes. Painful sensations arise only during walking, after removing shoes and kneading the foot, all signs of the disease fade away.
The last stage of the disease has pronounced symptoms, consisting in burning and shooting pain, which becomes constant. Such manifestations occur regardless of stress and shoes, and spread from the foot to the tips of the toes. The "older" the disease, the stronger the pain in the interdigital space, between the fourth and third fingers.
Diagnostics
Diagnosis of the disease is carried out in stages:
- Patient interview - history and clinical manifestations of the disease;
- Palpation - pressing on the area between the fourth and third toes in the transverse direction;
- X-ray and MRI - exclusion of diseases similar in symptoms, for example, arthritis or bone fracture;
- Administration of local anesthetics - used to locate the site.
Treatment
To eliminate Morton's neuroma, two methods of treatment are used:
- Conservative- carried out in the absence of permanent changes in the localization of the disease. The procedures and measures for this technique are aimed at eliminating pressure on the area of the damaged nerve. First of all, shoes are changed to more comfortable and loose ones, the use of orthopedic shoes and insoles is encouraged. Injections of corticosteroids, as well as analgesics, are mandatory. Patients are advised to undergo regular physiotherapy procedures;
- Operational- Surgical intervention is used if conservative therapy does not bring the desired result. The operation is a procedure performed under local anesthesia, during which the metatarsal canal is opened, after which the neuroma of the nerve is dissected or part of it removed. Removal can lead to temporary numbness in the area between the fingers, which is absent when the peroneural space expands. The rehabilitation period is usually ten to twelve days, during which it is recommended to wear only rational shoes, as well as to provide the forefoot with maximum rest. Short walking is possible the next day after the surgery.
There is a modern method of surgical removal of Morton's neuroma, which, due to the increase in the time of the rehabilitation period, is used extremely rarely. This technique - osteotomy of the four metatarsal bone, is aimed at curing the disease by achieving compression of the nerve. The procedure includes displacement of the head of the four metatarsal bone, which is performed after an artificial fracture (osteotomy). This technique has its advantages in the absence of scars, and disadvantages - an increase in the rehabilitation period.
Treatment with folk methods
With the help of traditional methods of treatment, it is impossible to eliminate the cause of Morton's neuroma. Thanks to traditional medicine, you can only get rid of the pain syndrome that accompanies the disease. For this, dressings impregnated with an infusion of bitter wormwood are widely used, for the preparation of which the wormwood herb is ground until a mushy state is obtained, and then placed on a gauze bandage. Apply the prepared solution to the painful area of the foot and leave it overnight, during which the pain goes away.
You can relieve pain with a warming compress, which is made from pork fat and table salt in a ratio of 100 grams. for 1 tbsp. l. The resulting mixture should be rubbed into the painful area, after which a gauze bandage should be applied to maintain heat.
You should use methods of treatment with folk remedies after consulting a specialist, since timely conservative treatment can eliminate the cause of the disease, which makes it possible for the patient to avoid surgery. Self-medication can lead to undesirable consequences in the form of complications of the disease.
Consequences and prognosis
If Morton's neuroma progresses for some time and is not properly treated, then there may be disappointing consequences, which include increased pain, further growth of education, and an increase in discomfort in the forefoot area.
As a result, there is a need for surgical intervention, otherwise, it becomes impossible to wear classic and model shoes, as well as to be in a standing position for a long period. You can forget about physical activity such as running, long walking, dancing or any sport.
Thus, if you experience the slightest pain in the forefoot, you should consult with a specialist who, after diagnostics, will determine the presence of Morton's neuroma disease and, if necessary, prescribe treatment.
It is known from everyday practice that foreign bodies are often introduced into the hand. They account for 1.7% of the damage. Once in the tissues, a foreign body causes a reaction from the surrounding tissues. The further course depends on the infection brought in with a foreign body and the state of the body. If the foreign body is aseptic, it will gradually encapsulate and may remain in the hand for many years. However, in the tissues surrounding the foreign body, a dormant infection often persists, and after many years a painful process may occur. Here is one of our observations.
45 year old woman N. sent to us for a consultation by a neurologist about right-sided plexitis, which is not inferior to long-term and varied physiotherapeutic treatment for five years. The cause of the disease is unknown to her, at first the pains were localized in the hand, and then spread throughout the arm, shoulder and neck. A few days ago, pain in the hand worsened, a swelling appeared at the base of the little finger.
Examination and palpation revealed: cyanosis and pastiness of the skin, smooth relief of the elevation of the little finger and wrist of the right hand, soreness and thickening of the V metacarpal bone, cohesion of soft tissues at the base of the palm, limitation of flexion, abduction and adduction of the little finger. Hyperesthesia of the skin, muscle atrophy by the type of ulnar nerve lesion. Diagnosed with chronic osteomyelitis of the 5th metacarpal bone, the patient was referred for an X-ray examination. X-ray diagnosis: foreign body in the thickness of the metacarpal bone, reactive osteoperiostitis.
Operation: after preparation of the skin, under local regional anesthesia with a longitudinal dorsal-lateral incision, the V metacarpal bone is exposed. Its periosteum is thickened, soldered to soft tissues. The bone was easily trepanned, from the bone marrow cavity, a needle covered with corrosion was removed from the granulation tissue. The granulations were removed, the cavity was scraped out, powdered with streptocide, a blind layer-by-layer wound suture, immobilization of the hand and forearm with a plaster cast. Healing is smooth, the pain in the arm has decreased. The patient recalled that the needle entered her hand while washing clothes 25 years ago. Surgeons often have to remove metal foreign bodies from the hand: needles, pieces of wire, metal, less often bones, wood, glass and other objects.
It is much easier to detect and clarify the location of contrasting foreign bodies during X-ray examination than to recognize non-contrasting bodies that have penetrated into tissues. X-ray of the hand is required in both cases, since sometimes it is possible to catch a light shadow on the film from both a fish bone and glass or a wooden splinter. Many different methods have been proposed for specifying the localization of foreign bodies, but for the hand the most simple and reliable are radiography in three projections and fluoroscopy. In this case, the point of greatest immersion of a foreign body is found when pressed, a sterile needle is brought to the foreign body, and then a convenient access is determined. Therefore, the presence of a surgeon is always recommended for radiography. A direct picture is taken in the position of the hand, corresponding to what it will have on the operating table; the second photograph is in a strictly lateral projection, it gives an idea of the depth of the foreign body.
Foreign bodies are more often retained in the metacarpus - 47%, then in the fingers - 36.8%, less often in the wrist - 10.1%. Occasionally, mainly with gunshot wounds, they are scattered throughout the hand - 2.5%, and in 3.6% the localization is not specified. Most surgeons believe that not all foreign bodies can be removed immediately. The only exceptions are graphite, pieces of paint that must be removed due to the danger of tissue necrosis caused by them.
We formulate the indications for the removal of a foreign body from the hand as follows. Foreign bodies are subject to removal: 1) visible to the eye and easily palpable; 2) hindering movements in the joints or interfering with the sliding of the tendons; 3) causing pain, pressing on blood vessels and nerves; 4) supporting inflammation; and 5) focusing the patient's attention.
The time and technique of surgical intervention are important. Of course, it is most advisable to remove foreign bodies immediately after injury. But this operation can be performed only if the surgeon has the appropriate time and conditions for the intervention, since this operation is often more difficult than expected. It is difficult to find fragments of a needle in the thickness of the eminence of the thumb, in the interosseous spaces of the metacarpus, in the canals of the wrist. Many times we ourselves repented of the haste of intervention and accepted victims from other medical institutions for repeated operations when the surgeon or the operating environment were not sufficiently prepared. Therefore, as an emergency operation, only visible and easily palpable foreign bodies are removed.
In other cases, the removal of foreign bodies from the hand is a planned operation that requires preliminary preparation of the patient and the surgeon.
Surgery plan: infiltration anesthesia is not recommended, as the injected novocaine displaces tissues. Regional, conduction, intraosseous or intravenous anesthesia or general anesthesia and exsanguination with a Korotkoff cuff should be applied. The skin incision is made over the foreign body in the longitudinal or oblique direction, depending on the location. After dissection of the skin and tissue, the edges of the wound are stitched with silk. These "holders" allow you to open the wound and carefully examine it before dissecting the aponeurosis.
Practice shows that with a correctly selected approach, a dark point, or a scar, or infiltrated tissues, indicating the path of entry of a foreign body, are visible on the aponeurosis. Note that several times, examining the wound with the naked eye, we did not notice these signs. Inspection with a magnifying glass helped to figure it out. After examining the aponeurosis, the latter is dissected and the tissues are carefully examined again.
So, going deep in layers, the surgeon looks for a foreign body where it was identified during a preliminary study. If it is necessary to pass between the tendon sheaths or muscles, it is necessary to avoid forcible separation of them and dissect the tissues, in accordance with the anatomical relationships.
Sometimes a foreign body can be palpated in the wound with a finger, but the palpation must also be carried out very gently and methodically, comparing it with the topographic and anatomical picture of the operated area. Finally, in case of unsuccessful searches, it is important to stop the operation in time, without going beyond the limits of admissibility of tissue injury, followed by functional disorders. Among our observations, there are cases of severe purulent infection after removal of the needle in an unfavorable environment.
Removal of foreign bodies from under the nail. Wooden splinters, pieces of fish bone or needles and other objects fall under the nail. A foreign body under the nail causes acute pain and is often visible with the eye, so the victim (or someone close to him) tries to remove it and breaks off the free end and only then goes to the doctor.
Rice. 141. Foreign body (window bolt) in the proximal interphalangeal joint of the second finger of the left hand.
In such cases, it is recommended to perform a wedge-shaped resection of the nail, free the end of the foreign body enough to grab it with tweezers, and remove it with a smooth movement. After removing the splinter, the wound is smeared with iodine tincture, powdered with streptocide and sealed with collodion. The dressing is changed rarely, as long as the nail grows.
The healing of the surgical wound after removal of foreign bodies in 88.9% of patients occurred by primary intention, in 7.5% - by secondary intention, 3.6% of these data were not in the case histories. Before the operation to remove a foreign body, a prophylactic dose of 1500 AU of anti-tetanus serum is administered. When removing foreign bodies from the hand, there are difficulties not only in finding them, but also in removing them from the tissues. Here is one of the observations.
Have stampers L... the index finger fell under the stamp, and another piece of the "window bolt" was driven into the proximal interphalangeal joint of the second finger (Fig. 141). At the health center, they unsuccessfully tried to remove the part, after which the victim was taken to the hospital. She complained of aching pain in her entire arm. Operation under general anesthesia. The part had to be knocked out from the rear to the palm with careful blows of a chisel and chisel. After removing the part, the epimetaphysis of the middle phalanx was resected, the deep flexor tendon was sutured, the fragments of the proximal phalanx were compared, the finger was given a functional position, and the wound was sutured; immobilization of the hand with a back plaster splint. The wounds healed without complications. The finger is in a functionally advantageous position, passively movable in the interphalangeal joints. The treatment lasted 32 days. Was it worth keeping the left index finger of a 50-year-old worker in the event of a crush on the proximal interphalangeal joint and damage to the flexor and extensor tendons of the finger? The victim herself answered this question three years after the injury: “My finger works normally, almost no one notices, and I forget that it does not bend on its own”.
The average number of days of disability with foreign bodies of the hand is 9.9.
Removing the ring from your finger
In case of injuries and purulent diseases of the fingers and hand, it may be necessary to remove the ring from the finger. If there is still no reactive edema, then it is enough to raise the patient's hand and hold it in this position for 3-5 minutes, lightly massaging the finger from the distal phalanx to the proximal one, then lubricate the skin with vaseline oil, and the ring can be removed with rotational movements.
Rice. 142. Removal of a splinter from underneath (a); removal of the ring with a thread (b).
The situation is different if the patient has been suffering from pain for several days, the hand and fingers are swollen, the ring has cut into the soft tissues and when trying to advance it, the pain sharply aggravates. The patient asks for the ring to be bitten or sawed. This succeeds if the ring is "hollow" or very thin; in most cases, the ring will not bite. It can be sawed if there is a file and a hand vice in the surgery.
If these tools are not available, then this attempt is unsuccessful, and the patient is sent to the jeweler. Meanwhile, the ring is almost always removed with a silk thread. A thick silk thread 50-60 cm long is taken, and one end of it is held under the ring from the nail to the base of the finger. The long end is tightly wound around the finger, back to back, so that not a single millimeter of skin is left that is not entwined with a thread from the ring to the nail. The finger is lubricated with sterile vaseline oil. After that, the end of the thread, brought under the ring, is pulled, bent over the ring, and the thread is slowly unwound. The ring, under pressure from the proximal edge of the thread sliding along it, moves and gradually slides off (Fig. 142).
E. V. Usoltseva, K. I. Mashkara
Surgery for diseases and injuries of the hand
Foreign bodies of the hands (splinters, needles) and the plantar surface of the feet (glass, splinters) are very common in the practical work of a paramedic. Metal foreign bodies (needles) most often penetrate the wrist in women when sewing, washing clothes and washing the floor. It is not uncommon for the needle to hit the soft tissues of the buttocks if the needle was broken during the injection. Splinters, that is, pieces of wood, often get into the soft tissues of the fingers and the tissues of the foot when walking without shoes. In the woodworking industry, it is not uncommon for large pieces of wood to fall into when servicing an electric saw and other mechanisms. Foreign bodies are often pieces of glass trapped in the soft tissues of the hand, forearm and soles. Metal foreign bodies in the form of pieces of wire and metal shavings are found in the metallurgical industry and in other industries in the processing of metals.
Shot wounds give multiple foreign bodies, often in different parts of the body. Sharp foreign bodies, such as needles, are usually located near the site of their introduction and are displaced in the tissues only for short distances. Therefore, the widespread opinion about the need to quickly remove a foreign body, in particular a needle, has no basis, although a needle that has penetrated into muscles or is located near them can move a short distance under the influence of muscle contraction. A larger foreign body can also move, usually with the surrounding accumulation of pus.
Foreign bodies, usually infected, often give an inflammatory process in their circumference, can cause the formation of an abscess, and they are released with pus outward or lead to the formation of a persistent fistula. Even encapsulated foreign bodies can give rise to an outbreak of infection, including anaerobic infection, especially if the capsule is broken.
Symptoms... Recognizing that a foreign body has entered the wound is sometimes very difficult. Anamnestic data, that is, the study of the mechanism of damage (injury by glass, etc.), allows to suspect a foreign body. It may suggest the presence of a foreign body, soreness under pressure on a foreign body located deep in the tissues, but this symptom in the first days after injury may also depend on the inflammatory process in the wound. It becomes more reliable with the preservation of local pain in the following days, when the inflammatory process caused by damage subsides. The presence of a focal inflammatory process in the depths of the tissues, interfering with physical work or walking and giving a restriction of working capacity, often indicates the presence of a foreign body in the palm or sole. An inflammatory process that lasts a long time after injury, especially the formation of a fistulous course, is often also a symptom of a foreign body deep in the tissues.
The most reliable method of examination in the presence of a foreign body in the wound is X-ray, which gives clear indications for metallic foreign bodies and the ingress of certain types of glass.
First aid. Foreign bodies sticking out of the wound are usually removed during first aid. In case of foreign bodies in the form of pieces of wood (splinters), they must be removed carefully, along the axis of the foreign body, so as not to break it and thus make it difficult to completely remove it. Deeply located foreign bodies, in particular needles, should not be found in the wound when providing first aid.
During the initial treatment of a surgical wound, all foreign bodies that are in the wound cavity and are accessible to direct palpation must be removed. Deeper foreign bodies are removed or retained, depending on their location. Multiple foreign bodies (small fragments, pellets) cannot always be removed with a large number of them and possible impairment of limb functions with multiple incisions.
Foreign bodies that give functional disorders and are complicated by the formation of a purulent process or the presence of a fistula and are dangerous in their location (the proximity of large vessels or nerves) must be removed after a special X-ray examination to clarify their localization. After removing a foreign body, even at a later date after injury, it is necessary to inject anti-tetanus serum according to Bezredka.
Emergency surgical care, A.N. Velikoretsky, 1964
Foreign bodies are called objects alien to the body, trapped in soft tissues, cavities or natural openings.
By the mechanism of entry and localization, they are distinguished:
- foreign bodies of soft tissues;
- foreign bodies of cavities (chest, abdominal);
- foreign bodies of organs (for example, eyes);
- foreign bodies of the gastrointestinal tract.
In the practice of an outpatient surgeon, soft tissue foreign bodies are most often encountered.
The main reason for the ingress of foreign bodies into soft tissues is a household or work injury. Foreign bodies can be in the form of chips (splinters), glass, metal shavings and many others.
Symptoms, diagnostics of foreign bodies.
There is always a wound (from a punctate to a rather large one) at the site of a foreign body. Patients complain of pain, sometimes a foreign body is visible under the skin or it is determined by palpation. In some cases, one can only assume the presence of a foreign body in the tissues (for example, with multiple cuts by glass fragments).
If the foreign body is radiopaque (metal - always, other materials - not always), the diagnosis helps to clarify the X-ray examination.
In the photo - a foreign body - a fragment of a needle in the soft tissues of a finger.
In the photo - a foreign body - a bullet from an air rifle in the finger of a hand.
When a foreign body enters the tissue around it, an abscess begins to form. In the area where the foreign body is located, pains, swelling, redness appear and increase. A purulent fistula may form, which does not heal, because the process is supported by a foreign body. The fistula will persist until the foreign body rejects itself or is surgically removed. In some cases, small foreign bodies are encapsulated without suppuration. After encapsulation, the danger of suppuration remains at a later date. Around the old encapsulated foreign bodies, chronic inflammation can begin, manifesting itself as moderate pain and the formation of a seal around the foreign body - granuloma.
Foreign body treatment - foreign body removal.
The main method of treatment is surgical. Soft tissue foreign bodies are removed under local anesthesia. In some cases, when one end of a foreign body protrudes outward, it is possible to remove it with forceps or a clamp without anesthesia. In other cases, the foreign body is removed through the incision. It should be remembered that small foreign bodies can be difficult to detect in tissues. Therefore, the operation should be resorted to when the foreign body is clearly palpated or shines through the skin, or is visible on x-ray. Otherwise, it is possible that the body simply will not be found during the operation. If there are doubts about the presence of a foreign body or the impossibility of determining its exact localization, observation is carried out. In case of suppuration, an operation is performed, and usually a foreign body is easily detected at the epicenter of the suppuration. When a granuloma is formed, it is excised along with a foreign body.
Loading ...