Learning Objectives

At the conclusion of this educational activity, participants should be able to:

• Describe principles of wound management for contaminated traumatic lacerations of the skin and soft tissue
• Identify risk factors for infection of traumatic lacerations of the skin and soft tissue
• Explain how the risks and benefits of foreign body removal from a traumatic laceration vary with the type of foreign body involved
• Describe the role of different imaging modalities in the management of foreign bodies associated with traumatic lacerations

The Case

A man with a history of hypertension and fatty liver disease presented to a local emergency department (ED) after a motorcycle crash. He lost control in a turn and landed in the dirt on the side of the road. He was wearing a helmet and denied head injury, loss of consciousness, or neck pain. However, he was only wearing a short sleeve shirt and jeans, not his usual riding jacket. On exam, vital signs were normal, and the physician documented two “superficial lacerations over the left olecranon with some wood chips in them.” X-rays were ordered and the radiologist noted “multiple tiny foreign bodies adjacent to the olecranon process.” The ED physician documented that “foreign bodies were removed, the wounds were scrubbed and sutured with loose closure.” No repeat x-ray was performed. The patient was discharged home with a prescription for cephalexin and instructions to return in 10-14 days for suture removal.

Three days later, the patient returned to the same ED for increased pain, swelling, and redness involving the left elbow. He denied fever or chills, and vital signs were again normal. The ED physician noted erythema, induration, and drainage of pus. The sutures were removed, the wound was irrigated, and additional wood fragments and gravel were removed. The wound was packed open, and the patient was sent home with doxycycline to add to the cephalexin. On a scheduled return visit the following day, the wound was inspected and sutured again, but no x-rays were obtained. Eleven days later, one or two days after finishing doxycycline, the patient went to an urgent care clinic for ongoing swelling, redness, and drainage from the elbow wounds. He denied fever or chills, and vital signs were again normal. The sutures were removed, the wound was explored, and more foreign material was extracted (described as soil plus a “1 cm x 3 cm piece of wood”). No x-ray was taken, and the patient was sent home on oral clindamycin and referred to his primary care physician for follow-up with a surgeon. The patient eventually developed osteomyelitis requiring multiple operations and a prolonged hospital stay.

The Commentary

By David K. Barnes, MD, FACEP and Garth Utter, MD, MSc, FACS

Background

This case illustrates the patient safety risks inherent to wounds contaminated by foreign material. Grossly contaminated wounds require meticulous attention, including debridement of devitalized tissue, removal of foreign material, and close surveillance for infection. But even seemingly minor wounds may harbor foreign matter that may lead to a future complication, including infection. The urge to close a wound acutely for cosmesis, patient preference, or anticipated simplification of wound care must be weighed against the risk of infection due to contamination, devitalized tissue, and less commonly but importantly, macroscopic foreign material closed inside the wound. Rarely, these infections can develop into life-threatening, rapidly progressing necrotizing soft tissue infections. When a patient returns with infection of a traumatic wound, retained foreign material should always be suspected. Infected wounds with retained foreign material often require operative exploration.

Some aspects of treatment during the index visit were appropriate. The wounds presumably were irrigated (the case mentions they were “scrubbed”), imaging was performed, and foreign body removal was attempted. These are necessary interventions for all similar wounds. However, any wound exploration was clearly far from thorough—it missed a 1 cm x 3 cm piece of wood (and likely other wood fragments, gravel, and soil). There should have been an evaluation for traumatic arthrotomy, and post-debridement radiographs should have been performed followed by additional exploration (or surgical consultation) if foreign material was still evident. There is no mention of tetanus immunization status, but a heavily contaminated wound should prompt consideration of repeat vaccination with tetanus toxoid and even administration of tetanus immune globulin for at-risk individuals.

We do not have details about the age of the patient or the time from injury to laceration repair, but a relatively high-energy, blunt mechanism of injury causing an extremity laceration with entrained foreign bodies warrants considerable caution before closure of the wound is considered. Even if the first physician were confident that all foreign matter was removed, it would have been prudent to leave the wound open and recheck it for a developing infection a few days later. Prescribing empiric oral antibiotics is common practice for similar wounds, but the routine use of antibiotics in this setting is not supported by robust evidence. Moreover, some might erroneously conclude that the use of antibiotics absolves a clinician of their duty to remove foreign matter from a wound, but in fact, removal of foreign material is the mainstay of treatment and often obviates the need for antibiotics.

Close follow-up should have been arranged sooner than was planned for assessment of wound healing. While this follow-up would not have prevented the infection, it may have led to its earlier identification, potentially leading to a better outcome. Once infection was identified, consultation with a surgeon for operative exploration, debridement, and foreign body removal should have occurred.

General Approach to Wounds

Although a complete overview of wound care fundamentals is beyond the scope of this commentary, a few basic principles bear reviewing. (NB: While we use the terms “foreign contaminant”, “foreign material”, and “foreign body” interchangeably, foreign contaminant and foreign material usually refer to particulate material such as dirt, soil, and saliva, while foreign body usually refers to a discrete object such as a bullet, glass fragment, or wood chip.)

Lacerations and other wounds are amongst the most common conditions encountered in emergency departments (EDs). In the U.S. in 2005, these injuries accounted for more than 11 million ED visits,^1,2 although this number appears to be decreasing in recent years with greater use of other care settings.³ Most wounds do not contain foreign material or foreign bodies, can be closed primarily, and heal uneventfully. Medical error occurs when a clinician neglects to identify and remove foreign matter associated with a wound. Patient harm occurs when retained foreign matter leads to avoidable infection, discomfort, delayed healing, or impaired biomechanical function. Complications (e.g., cellulitis, abscess, osteomyelitis, fistula, mechanical impairment, etc.) may occur soon after the initial injury, especially with retained organic material, or may be delayed by months or years, especially with inert material.

Both the past medical history and the history of the injury itself are important to ascertain. Past medical history identifies patient-level risk factors that affect wound healing. Extremes of age, diabetes mellitus, history of smoking, peripheral arterial disease, chronic renal failure, obesity, malnutrition, immunosuppression, and inherited connective tissue diseases are associated with delayed or compromised wound healing.²

Eliciting the mechanism of injury will identify factors extrinsic to the patient that increase the risk of wound complications such as foreign body contamination, arthrotomy, tendon laceration, or open fracture. Bites (especially human), soil contamination, crush injuries, stellate lacerations, and lacerations over normally sterile structures (e.g., tendons, bones, and joints) are all associated with increased risk of delayed wound infection.² Wounds due to a patient sliding into dirt or gravel (as in this case) almost always contain some foreign material, while a laceration from a kitchen knife may contain foreign matter (e.g., food) but is considered low risk for a foreign body.⁴ Impalement injuries may result in fragments of clothing, or the impaled object being deposited deep into the wound. Cultural or linguistic barriers, or fears of legal or occupational consequences, may interfere with obtaining a complete and truthful history of the circumstances of the injury.

Generally, skin laceration management should also consider the possibility of injury to deeper structures causing neurovascular injuries, fractures, or, for the torso, hemopneumothorax or intra-abdominal injury. Before exploring an extremity wound, clinicians should perform a thorough neurovascular assessment including presence and strength of pulses, motor function, and sensation distal to the injury. After adequate topical, local, or regional analgesia, and with the patient in a comfortable (usually supine) position, wounds should be examined to their base in a bloodless, well-exposed, brightly lit field for evidence of traumatic arthrotomy, tendon injury, arterial injury, open fracture, and foreign material.^4,5

In patients with an intact immune system, “the mainstay of wound healing is within the fresh wound itself—the natural healing process.”¹ Nevertheless, clinicians should provide care and treatment that optimizes that natural healing environment. Wounds should be irrigated with moderate pressure (5-8 psi) irrigant to reduce bacterial counts and flush gross contaminants from the wound, especially if wound closure is planned.⁵ Which irrigant is best has been debated and still not settled. Sterile water and sterile saline are used commonly but are expensive; evidence suggests tap water irrigation is not inferior to either one.^1,2,6 Wound cleansers, such as hypochlorous acid, are recommended as safe and effective by the WHO (World Health Organization) and may be superior to saline or water.⁷ Alcohol, povidone/iodine, chlorhexidine, and hydrogen peroxide should be avoided because they are painful when applied, toxic to injured tissue, and can impair wound healing.¹

Wound Foreign Matter

In a retrospective review of 200 patients with confirmed foreign bodies in the hand, the diagnosis was missed by the initial treating physician in 38%.⁸ Not surprisingly, missed foreign bodies are a leading cause of lawsuits in emergency medicine.⁹ Therefore, conventional wisdom dictates that all foreign bodies be removed from wounds, but there are exceptions to this dogma. Any decision to remove a foreign body should include consideration of the risk of symptoms and complications (including infection) if the foreign body is left in situ. Additionally, the risk of wound exploration and the physical removal of the foreign body itself must be considered because damage to important structures (e.g., arteries, nerves, tendons) may occur.¹⁰ Sometimes, foreign bodies located superficially or within the exposed wound can be adequately removed during a bedside procedure, but in many cases, removal of deeply embedded foreign bodies or foreign bodies adjacent to delicate anatomic structures should be performed in a controlled surgical environment. Rarely, leaving a foreign body in place is preferred.

In general, wood, soil, vegetative material, and other matter with porous surfaces (e.g., clothing fragments) should be removed from wounds because there is high risk of inflammation and infection if neglected. Foreign bodies composed of non-organic material, such as metal or plastic, may not require removal as these pose a lower risk of infection than organic matter. If a foreign body causes pain or risks damage to a vital structure from chronic irritation (e.g., a sharp metallic fragment adjacent to a major artery), surgeons should usually consider removing it. However, removal of non-organic material need not be performed at the time of the initial evaluation.¹⁰ A good example of the potential complexity of such decision-making is a close-range shotgun wound: it is usually not feasible or desirable to remove all retained metallic shot, which are at relatively low risk of causing infection. But devitalized tissue must be addressed, and the “wad” (a plastic cup positioned between the powder charge and the shot in the shotgun shell), as well as clothing fragments, can become entrained in the wound and frequently cause infection. If in doubt about how to manage potential foreign bodies, clinicians should have a low threshold for involving an experienced trauma surgeon.

Unfortunately, wounds may contain occult foreign material that is not visible or palpable during an exam and not detectable on diagnostic imaging. It is therefore imperative to maintain a high index of suspicion for foreign material when assessing all wounds, especially wounds associated with a high-risk mechanism. Clinicians should exclude the presence of a foreign body to the best of their ability through a detailed history, wound exploration, and, if needed, imaging. Occasionally, the only evidence of a foreign body is a persistent infection or sinus tract that fails to resolve with standard treatment. Undoubtedly, some foreign bodies (especially small ones made of inert material) are simply never detected.

Role of Imaging

The treating physician documented the presence of visible foreign material in the wound. Radiographs likely confirmed what was seen on exam. While the full radiology report is unavailable, the listed finding suggested the presence of additional unseen debris. Some foreign body removal was performed, but one wonders why the physician was so confident in their removal of all foreign material that wound closure was deemed appropriate. This determination is challenging even with a post-debridement radiograph, as many foreign bodies are too small to be seen with imaging, even if they are radiopaque. Moreover, complete foreign body removal can be difficult in the ED setting, even with thorough attempts.

Imaging plays an important role in the detection of foreign material, not just identification of fractures and dislocations. If a clinician suspects a foreign body but is unable to identify it during wound exploration, imaging is indicated. Imaging may also be indicated to quantify the number and distribution of foreign material that is seen on exam. Several imaging modalities are available, each with unique performance characteristics, advantages, and limitations.

When confronted with a possible wound foreign body, most clinicians begin with plain radiographs, ideally with views in at least two anatomic planes.¹¹ These views are inexpensive (relative to more advanced cross-sectional imaging), universally available, completed quickly, associated with minimal radiation, and interpretable by non-radiologists. Diagnostic radiography can detect radiopaque material 1-2 mm or greater in size 80-95% of the time. Glass fragments generally are considered radiopaque, independent of lead or other content; however, they are harder to detect when very small or obscured by bone.¹² For smaller and non-metallic or otherwise radiolucent objects, such as wood chips, cactus spines, and plastics, plain radiographs have poor sensitivity.¹³

Computed tomography (CT) is best used when a foreign body is suspected but not detected by plain radiographs. While CT is more expensive, takes longer to complete, demands higher radiation dosing, and requires interpretation by a radiologist, it has better resolution and the ability to localize material in three dimensions, making it superior to plain radiography.¹³ CT has the additional benefit of reliably identifying or excluding traumatic arthrotomy, probably even better than a joint challenge (i.e., arthrogram).¹⁴ Magnetic resonance (MR) imaging accurately detects wound foreign bodies but is more expensive and not as readily available.¹³

Because most foreign body materials are hard (i.e., their acoustic impedance differs from that of soft tissue), point of care ultrasound (US) has emerged as an effective imaging modality to interrogate soft tissue for foreign bodies, even those that are not visible by diagnostic radiography.¹⁵ In a study of 31 patients with a suspected radiolucent foreign body (i.e., wood splinter), the area of interest was investigated with plain radiography, CT, and US. With operative exploration as the criterion standard, the accuracy of US to detect radiolucent foreign bodies was 90% compared with 70% for CT.¹⁶ The accuracy of US is better when the foreign body is in superficial (as opposed to deep) tissue and is highly dependent on operator skill and experience.¹³

While imaging plays an important role in the diagnosis of wound foreign bodies, the role of repeat imaging after attempted foreign body removal is undefined. To our knowledge, there have not been any published studies that investigated the utility of repeat imaging after attempted foreign body removal. Common sense suggests that, if the number of foreign bodies on imaging were to match the number of objects removed, additional imaging might not be necessary. But foreign bodies may fragment during removal, represent a mix of radiopaque and radiolucent items, or obscure each other on imaging (leading to an unreliable radiographic count). Therefore, it is common practice to repeat the radiograph to “prove” complete removal. By similar logic, if the number of foreign bodies seen on imaging exceeds the number removed, additional imaging (or surgical consultation) is typically indicated. Because multiple radiopaque foreign bodies were noted on the plain radiographs at the first visit, it would have been wise to re-image after the initial attempt at removal to assess for any remaining material.

Risk of Infection and the Role of Antibiotics

High risk wounds require attention to reducing infection risk, including wound decontamination, close follow up, consideration of empiric antibiotic treatment, and caution before performing primary wound closure. It is usually better to assume an infection will occur than to hope it won’t. Suturing a wound with retained organic foreign material all but ensures an infection will develop. If foreign material cannot be excluded to a high degree of probability, it is better to leave a wound open and reevaluate it frequently for possible delayed closure or healing by secondary intention. The anatomic location of a wound affects infection risk. Scalp and facial wounds are resistant to infection, while wounds on the extremities are more prone to infection because skin perfusion is less robust.

The physician in this case was concerned enough about a possible wound infection and reasonably prescribed cephalexin. Although evidence strongly supports antibiotic administration prior to elective surgical incisions to reduce wound infections (true prophylaxis), this timing is not possible for traumatic wounds. We might more accurately describe such antibiotic use as “early empiric treatment,” which is not strongly supported by evidence. In a meta-analysis of 7 randomized trials inclusive of 1734 patients, there was no benefit to early empiric antibiotic treatment (termed “prophylactic” by the authors) for patients with non-bite wounds. In fact, there was a slight increase in the infection risk in patients treated with early empiric antibiotics compared to untreated controls (odds ratio = 1.16, 95% confidence interval 0.77-1.78).¹⁷ While it may be reasonable to prescribe antibiotics to patients with high-risk wounds, an antibiotic is not a substitute for thorough wound decontamination and removal of foreign bodies at high risk for causing infection. Even the strongest antibiotic will not prevent a wound infection due to retained organic matter.

For all wounds, it is prudent to convey to the patient that a foreign body was excluded to the best of the clinician’s ability. If there is uncertainty that a foreign body was not completely removed, or if one cannot be excluded by exam (with or without imaging), verbal and written discharge instructions should note the possibility of a retained foreign body, and the patient should be given clear instructions about monitoring for symptoms that could indicate a retained foreign body and a developing infection. These patients should be referred for a follow up examination and possible outpatient imaging or specialist evaluation. The wound examination and discussion with the patient should be clearly documented in the medical record.¹

To Close or Not to Close…

If the failure to completely remove all foreign material from the two elbow wounds—or at least to appreciate that more thorough evaluation of the wound was required in the operating room—was the most obvious error in this case, the decision to close the wounds with sutures comes as a close second. Closing foreign material into a wound creates an ideal environment for bacteria to thrive, especially anaerobic bacteria.

Clean, relatively fresh, well-irrigated traumatic lacerations, without retained foreign material or damaged or devitalized tissue, usually warrant primary closure, but patient comorbidities and the anatomic location of the laceration influence infection risk. Lacerations over joints require longer suture dwell times because these wounds face higher tensile skin stress. Importantly, lacerations from blunt injury involve greater tissue damage invisible to the naked eye and these wounds require not just closer follow-up than the 10-14 days recommended in this case, but sometimes longer duration follow up to ensure complete healing.

Conventional wisdom holds that wounds older than a few hours (depending on their anatomic location) should not be closed primarily because older wounds represent a higher risk for infection. Unfortunately, evidence supporting this practice is limited. The authors of a 2013 systematic review sought to determine the effect on time to healing and adverse effects of primary wound closure (versus delayed closure) for non-bite traumatic wounds and determined that there is “currently no systematic evidence to dictate a change in clinical practice regarding the timing of closure of non-bite traumatic wounds within the first 24 hours of injury.”¹⁸ A more recent systematic review examined evidence for the conventional 12 hour “golden period” of wound closure. The authors could not conclusively determine a specific cut-off for primary wound closure, citing multiple low-quality studies upon which current practice is based. They did, however, note several criteria that should prompt a clinician to consider delayed wound closure (i.e., tertiary closure, or what the authors refer to as “delayed primary closure”): wound length greater than 5 cm, location on the extremities, contamination with foreign material, diabetes, and age of 75 years or older.¹⁹

We recommend a patient-centered approach regarding the decision as to whether and when to close a wound. If primary suture repair is deemed too risky, the wound might be best treated with delayed primary closure 3 to 5 days after injury, when the risk of infection is often decreased. For some patients, probably including the one in this case, even delayed closure is not feasible or may result in a poor outcome and therefore healing by secondary intention—the slow granulation, contraction, and re-epithelialization of the wound over weeks to months—is preferred. These methods are suitable for larger wounds or those associated with higher infection risk.²

Follow Up

When a patient returns for evaluation of an injury and there is objective worsening since the initial visit, a judicious physician should resist diagnostic momentum. However, this patient presented for acute care four times—to 3 EDs and 1 urgent care clinic—over 15 days, and yet the clinicians at each subsequent visit did not escalate care despite the patient’s worsening clinical status. Each subsequent visit represented a failed opportunity to identify the evolving complication from the first visit and to intervene to prevent the eventual poor outcome of osteomyelitis. With slightly different circumstances or delays in opening the wound or administering antibiotics, the outcome could have been even worse, resulting in extensive soft tissue debridement, arm amputation, or death.

Ideally, all patients with high-risk wounds should have close follow up, usually within 24-48 hours. For patients who are not hospitalized, this visit can often be scheduled with the patient’s primary care physician, but a return visit to the initial ED, with or without evaluation by a general or trauma surgeon, may be necessary under some circumstances. Wounds that fail to heal or have persistent pain or drainage should be considered to have a retained foreign body, and consultation with a surgeon for operative exploration is indicated.⁴ In the presented case, when the infected wound was opened at the first follow-up visit and additional wood fragments and gravel were identified, failure to involve physicians more experienced in wound care, or to hospitalize the patient to administer intravenous antibiotics and monitor the course of the infection, was a missed opportunity. Mismanagement clearly begot more mismanagement when the infected wound was then apparently and inexplicably closed again with sutures the next day.

System Optimization and Quality Improvement Approach

We propose three processes that may lead to improved outcomes in patients with high-risk wounds. First, a standardized approach to wound exploration and management, including wounds near or over a joint, will ensure that all wounds—regardless of location or severity—are treated with the same care and caution. While most wounds do not contain foreign material, we submit that the best way to avoid missing the presence of retained foreign material in a wound is to assume it is present until the examination, imaging, or both, exclude it to a reasonable degree. All wounds should be considered at risk for foreign bodies and treated accordingly with exploration in a bloodless, brightly lit field. Documentation of that process should follow accordingly.

Second, if a foreign body cannot be excluded based on thorough examination of the wound, or if the clinician suspects a foreign body prior to exploration, imaging should be obtained. The chosen imaging modality will depend on local resources and expertise, but also on the suspected composition of the foreign material. Diagnostic radiographs suffice for most metallic foreign bodies, but CT and US offer advantages when foreign material is small or radiolucent, and when joint violation is possible. If imaging is performed, repeating the study after attempting removal of the foreign material is recommended. If any doubt remains—especially when retained organic material is suspected or when a patient returns with a delayed infection—surgical consultation for formal operative exploration is warranted.

Third, wounds meeting high risk criteria (as defined above) should be left open and re-examined at a scheduled follow up visit in 24-48 hours; delayed closure, if indicated, can be considered 3-5 days post-injury if infection is excluded at that point. Ideally, processes should exist to ensure that follow up occurs within a defined period with a specific clinician or clinic. Alternatively, patients should be instructed to return to the index ED for re-evaluation.

Take-Home Points

• Evaluate all patients for their risk of wound infection and poor wound healing. Patient factors and the history of present illness contribute to wound outcomes.
• Blunt lacerations—as opposed to penetrating injuries—frequently involve tissue damage and devitalization, which is simply culture medium for bacteria to grow.
• Anesthetize wounds and thoroughly explore to the base to determine if there are foreign bodies or damage to underlying structures.
• Plain radiography, computed tomography, and ultrasound are useful imaging modalities that can identify, localize, and quantify foreign material in wounds.
• When reasonable and appropriate, avoid primary closure of high-risk wounds, such as animal bites, dirty wounds, and those where there is a risk of retained foreign material. Delayed (tertiary) closure or healing by secondary intention is acceptable and sometimes preferable in these circumstances.
• Have a low threshold for surgical exploration of a wound in an operating room if there is suspicion of a retained foreign body causing a wound infection.
• Wounds close to a joint warrant imaging (i.e., CT) or a joint challenge (i.e., saline arthrogram) to evaluate for arthrotomy.
• Two day wound checks are likely not necessarily in all cases but should be routine for high-risk wounds.

David K. Barnes, MD, FACEP
Consulting Editor, AHRQ’s Patient Safety Network (PSNet)
Health Sciences Clinical Professor
Director of Faculty Development
Director of ED Sustainability
Department of Emergency Medicine
Physician Advisor
UC Davis Health
dbarnes@ucdavis.edu

Garth Utter, MD, MSc, FACS
Consulting Editor, AHRQ’s Patient Safety Network (PSNet)
Professor
Department of Surgery, Division of Trauma
UC Davis Health
ghutter@ucdavis.edu
 

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