11.06 Superficial Sliver

agk’s Library of Common Simple Emergencies

Presentation

The patient has caught himself on a sharp splinter (usually wooden) and either cannot grasp it, has broken it trying to remove it, or has found it is too large and painful to remove. The history may be somewhat obscure. On examination, you should find a puncture wound with a tightly embedded sliver that may or may not be palpable over its entire length. There may only be a puncture wound without a clearly visible or palpable foreign body.

What to do:

Obtain a careful history. Find out if the patient has any foreign body sensation. Be suspicious of all puncture wounds (especially on the foot) that have been caused by a wooden object.
If it is unclear whether a wooden foreign body is beneath the skin, order a high resolution ultrasound study employing a linear array transducer that focuses in the near field of view.
Locally infiltrate with 1% Xylocaine with epinephrine (use no epinephrine in a digit) and clean skin with povidone- iodine solution.
Using a #15 blade, cut down over the entire length of the sliver, completely exposing it.
The sliver can now be easily lifted out and removed.
Cleanse the track with normal saline or 1% povidone-iodine on a gauze sponge. Debride contaminated tissue if necessary.
If the sliver is not visible or easily palpable but you feel confident it is relatively superficial and buried within subcutaneous tissue, you may try excising the surrounding tissue. First, when possible, create a bloodless field by using a tourniquet or self-retaining retractors in combination with lidocaine with epinephrine. Make a narrow oval incision on the skin surface surrounding the puncture site. Undermine the outer wound edges and then excise the central skin plug along with the subcutaneous tissue containing the foreign body. Make certain that you have recovered the entire wooden fragment.
Close the wound with sutures or wound closure strips. Avoid sutures, especially absorbable buried sutures when possible because of the increased risk of infection.
Give tetanus prophylaxis, if necessary.
Warn the patient about the signs of infection and schedule a 48 hour wound check.

What not to do:

Do not order plain radiographs. Wooden foreign bodies are radiolucent. After one day absorbing water from adjacent tissue, then tend to be isodense on xerography and tomography. Other than wood, plastic, cactus and sea urchin spines, thorns and aluminum may be present, and all tend to be difficult to visualize on plain radiographs.
Do not try to pull the sliver out by one end. It is likely to break
Do not try to locate a foreign body in a bloody field.
Do not make an incision across a neurovascular bundle, tendon, or other important structure.
Do not attempt to remove a deep, poorly localized foreign body. Those cases should be referred to a surgeon for removal in the operating room, perhaps with fluroscopic or ultrasound guidance.
Do not rely entirely on ultrasound to rule out the possibility of a retained foreign body.
Do not be lulled into a false sense of security because the patient thinks the entire sliver has already been removed. This is often not the case.

Discussion

The most common error in the management of soft tissue foreign bodies is failure to detect their presence. An organic foreign body is almost certain to create an inflammatory response and become infected if any part of it is left beneath the skin. It is for this reason, along with the fact that wooden slivers tend to be friable and may break apart during removal, that complete exposure is generally necessary before the sliver can be taken out. Of course, very small and superficial slivers can be removed by loosening them and picking them out with a #18 gauge needle, avoiding the more elaborate technique described above. When only the outer skin layers are involved, reassuring the patient and gently manipulating the wound can usually obviate the need for anesthesia.

If the foreign body cannot be located, explain to the patient that you do not want to do any harm by exploring and excising any further, and that therefore, you will let the splinter become infected so it will “fester” and form a “pus pocket,” when it can be more easily removed. If this procedure is followed, it should always be coordinated with a followup surgeon. The patient should be placed on an antibiotic and provided with followup care within 48 hours.

When making an incision over a foreign body, always take the underlying anatomical structures into consideration. Never make an incision if there is any chance that you may sever a neurovascular bundle, tendon, or other important structure.

When a patient returns after being treated for a puncture wound and there is evidence of non-healing or recurrent exacerbations of inflammation, infection or drainage, assume that the wound still contains a foreign body and refer him for surgical consultation.

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