Wooden FB-Please Educate me.

[jmj11]

Okay, to be clear, I am not seeking advice for a family member, but I just want to understand things better. In 1990-94 I worked a small ED (Air Force) and then in 1998-2000 I did moonlighting in a ED fast track, so my experience is very limited in the ED enviroment, and a long time ago.

My son is a cabinet maker and gets splinters all the time. This morning, while working with some rough lumber, he felt a pain in his hand. He ignored until hours later when he could no longer move his thumb without a lot of pain. He noticed hole at the  top of his thenar eminence and the whole eminence was quite swollen and red (he sent me a photo). He had looked in the hole and didn't see evidence of a FB, but felt quite sure a chunk of wood was in his palm.

I remember seeing patients like him in our ED and (having limited imaging available in our small hospital, no US, no CT, no MRI) I would get a plain xray and if I saw the shadow of a FB, place a surface marker (bb) and re-xray it. If I could localize the point it was closet to the surface (and if it was not deep into muscle) I would numb it up, do a small incision (or go through the entry wound) and fish it out, usualy with success. Then I would put the patient on a soft-tissue antibiotic (in those days, Keflex) and see them in follow up or have them see their GP.

So, I advised my son to go to the fast track and if they couldn't take care of it they would send him to the ED. However, he went and the PA told him that "You can't see wood with an x ray" (which is partially true as a study said it will show up about 60% of the time with a plain film, while CT or MRI is >90%)1. and that there was nothing she could do for him and dismissed him. He left confused and forty bucks poorer.

So, was I just imagining that I was imaging all those wooden FBs I removed in the ED? (btw it was in Marquette, MI, a place where there were a lot of lumber jacks, woodworkers, and people who burned wood) How would you have handled it? I will have keep in contact with him and I will see him in a few days and see if I can get it out, or sending him back to the ED or GP if it is getting infected. Educate me.

Thanks, Mike

1.  https://www.sciencedirect.com/science/article/abs/pii/S0720048X20305854

[EMEDPA]

I still get the XR because sometimes you will see the fb.

If they feel it or I do I generally will go looking for it. 

[SedRate]

1 hour ago, EMEDPA said:

I still get the XR because sometimes you will see the fb.

If they feel it or I do I generally will go looking for it. 

Agree

[jmj11]

So I'm not nuts? Well maybe I'm nuts but not in this situation.

[SedRate]

9 hours ago, jmj11 said:

So I'm not nuts? Well maybe I'm nuts but not in this situation.

Not nuts when it comes to FB in hands. Lol

On 5/1/2024 at 9:42 PM, jmj11 said:

He ignored until hours later when he could no longer move his thumb without a lot of pain. He noticed hole at the  top of his thenar eminence and the whole eminence was quite swollen and red (he sent me a photo). He had looked in the hole and didn't see evidence of a FB, but felt quite sure a chunk of wood was in his palm

On 5/1/2024 at 9:42 PM, jmj11 said:

there was nothing she could do for him and dismissed him

May not exactly mirror kanavel signs but intense pain, redness, swelling, and inability to move the thumb is a red flag. I would've done something or at least sent to ED or consulted a hand specialist... ANYTHING than send pt home...

[Apollo1]

Wood absorbs water and becomes the same density as objects around it. Imaging usually doesn't see anything, and is a waste of time IMO. General recommendations are based on if a patient reports foreign body sensation you consider one lodged until otherwise ruled out. If exam doesn't reveal a FB and no other concerning features, it's reasonable to d/c with abx and outpt f/u with Ortho Hand.

You can place a banana peel over the broken skin to help draw out a wooden foreign body; we use it on peds pts sometimes.

[ohiovolffemtp]

I generally xray to evaluate for any FB, even wood.  I tape an unbent paper clip to the skin with the end at the puncture wound so I have a reference point if I have to try and remove the FB.  I usually cover with Keflex, sometimes add Bactrim for suspected MRSA.  In an ED, you could probably also go looking with U/S.

[SedRate]

17 hours ago, Apollo1 said:

it's reasonable to d/c with abx and outpt f/u with Ortho Hand

I'm curious, is this what the hand folks have advised you do? 

Edited May 4 by SedRate

[Apollo1]

Hand in my area doesn't have any specific preferences. If exam doesn't demonstrate anything and imaging doesn't show anything (usually the case) but the patient still reports FB sensation we send their way in case more invasive procedure is warranted. The textbooks put a lot pf emphasis on the patient reporting FB sensation as a marker for one being lodged, but as we all know there are plenty of folks who probably put themselves into a state of anxiety which doesn't provide clarity.

I still discuss w/ pt risks & benefits with superficial exploration in the department; if the pt is ok then will proceed.