Hot Seat #169 Denouement

Posted on: April 8, 2021, by :

The case: a 4 yo with an embedded foreign body and mildly elevated inflammatory markers

Here’s how you answered the questions:

Discussion:

This case raises many interesting questions regarding work up and management of a foreign body that has been in place for some time. In terms of the initial work up, the group was split pretty evenly between ultrasound and x-ray. Though Dr. Falk raised a good point that if one is thinking of consulting orthopedics for removal, it is worth thinking, “what would orthopedics want?”

The x-rays obtained demonstrate a foreign body in the soft tissue without boney abnormalities (and not in the bone). Again, the group was split on attempting to remove in the ED versus consulting orthopedics (or sedating and having orthopedics remove in the ED). A minority would obtain labs at this point.

Orthopedics was consulted, and requested labs, which demonstrated mildly elevated inflammatory markers. In terms of next steps, there was variability in asking orthopedics to remove the foreign body versus advocating for admission versus some who would attempt removal in the ED. Dr. Chapman raised the good point that if the patient is weight bearing and well appearing, discharge with clinic follow up may be a reasonable option as well. Dr. Lindgren raised the point that foreign body material matters. Wood is inflammatory and splinters easily so important to get orthopedics involved. Location is also important as feet get infected more than hands.

Ultimately, the patient was started on antibiotics and admitted to orthopedics for removal in the operating room.

Denouement: Orthopedics was consulted for this patient without an attempt by an ER physician at foreign body removal. Orthopedics recommended osteomyelitis work up labs (CBC, ESR, CRP, blood culture) which demonstrated an elevated WBC count and inflammatory markers. Orthopedics opted to admit the patient for wash out in the operating room under anesthesia. Per the operative note, the foreign body was removed with complication and there was a fluid collection around the foreign body. The patient stayed in the hospital a few days after foreign body removal for IV antibiotics and was discharged home on oral antibiotics. 

The information in these cases has been changed to protect patient identity and confidentiality. The images are only provided for educational purposes and members agree not to download them, share them, or otherwise use them for any other purpose.

Mary Beth Howard
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