How To Remove A Splinter From Under Nail

Splinter Removal

CHRISTINA CHAN, M.D., and GOHAR A. SALAM, M.D., D.O., Michigan Country University College of Man Medicine, Eastward Lansing, Michigan

Am Fam Medico. 2003 Jun 15;67(12):2557-2562.

Splinter injuries are common, simply larger and deeper splinters are often difficult and painful to remove at domicile. These splinters oftentimes nowadays as a foreign body embedded in the superficial or subcutaneous soft tissues. Whenever possible, reactive objects like woods, thorns, spines, and vegetative material should be removed immediately, before inflammation or infection occurs. Superficial horizontal splinters are mostly visible on inspection or easily palpated. A horizontal splinter is exposed completely past incising the skin over the length of the long axis of the splinter, and removed by lifting it out with forceps. A subungual splinter may be removed past cutting out a V-shaped piece of the nail. The indicate of the 5 is at the proximal tip of the splinter, which is grasped and removed, taking particular care not to push the splinter further into the boom bed. Removal of an elusive splinter can be challenging and may require the use of imaging modalities for better localization. Deeper splinters, especially those shut to important structures such every bit nerves, tendons, blood vessels, or vital organs, should be referred for removal.

Splinters are common in children and adults, nigh often presenting as a strange body embedded in the superficial or subcutaneous soft tissues of the extremities. Wood, drinking glass, and metallic splinters are among the most common retained strange bodies.1 Most superficial splinters may be removed by the patients themselves, leaving to physicians only the deeper and larger splinters, or retained splinters that have broken down during an attempt at removal.two If not removed completely, splinters may crusade complications such as inflammation, infection, toxic reactions, and granuloma formation. Failure to diagnose the strange body has emerged as a common crusade of malpractice actions against family physicians. Even later a foreign body has been found, the medico should ensure that cipher is left in the wound. The physician also must be cautious in telling the patient that the splinter is entirely removed. It may exist preferable to tell the patient that all of the visible splinter has been removed, but there is always a chance that small pieces may exist present that are undetectable at that time.

Evaluation

The well-nigh common fault in the management of soft tissue foreign bodies is the failure to discover their presence.2,3 A patient's suspicion that a strange body may exist present must be taken seriously. It is important to obtain a careful history, inquiring well-nigh the nature and timing of the injury, the composition of the textile most likely involved, and the presence of any strange-body awareness in the wound if the splinter is not readily visible. It is likewise of import to enquire almost, and document, the tetanus immunization condition of the patient.

The timing of the injury is important in evaluating splinters. A fresh injury usually has an injury track leading to the splinter that facilitates its detection and removal. Older injuries may present equally infection, inflammation, induration, or granuloma germination, sometimes with no credible history of strange-torso exposure. The limerick of the foreign torso dictates the reaction of the tissues to the splinter. Some types of foreign material are more toxic and allergic than others (Table 1).3,4 Wood, thorns, spines, and other vegetative foreign bodies are considered highly inflammatory, whereas glass, metallic, and plastic are relatively inert materials.five

TABLE i

Reactions to Retained Foreign Materials

Type of material	Reaction severity	Reaction type
Glass (uncontaminated)	Mild	Encapsulation
Blackthorns	Severe	Inflammatory reaction from alkaloids
Wood	Astringent	Infection, inflammatory reaction from oils and resins
Cactus spines	Moderate to severe	Inflammation from fungal coating on the plant; delayed hypersensitivity reaction
Rose thorns	Moderate to severe	Inflammation from fungal coating on the constitute
Sea urchins	Moderate to severe	Inflammation and infection; toxic and allergic reaction
Metallic	Mild	Encapsulation
Constitute spines (alkaloids)	Mild to severe	Toxic reaction
Beast spines	Balmy to severe	Toxic reaction
Plastic	Mild	Encapsulation

On concrete exam, well-nigh superficial splinters tin be visualized or palpated easily. Deeper splinters may be difficult to detect; at times, the only clue to the presence of retained foreign bodies may be swelling, tenderness, a mass, a draining sinus, or a soft tissue infection such as cellulitis, abscess, lymphangitis, bursitis, synovitis, arthritis, or osteomyelitis. While evaluating the patient with skin or soft tissue complaints, the physician should actively look for signs of a hidden foreign body (Table 2).3,4

An array of diagnostic tools is bachelor for detecting and locating splinters (Table iii).iii,4,half-dozen–11 The cost of an imaging modality and its likelihood of detecting the foreign body should exist considered before it is ordered. Standard radiographs are the well-nigh practical means of screening for a radiopaque foreign body.3 Near all drinking glass is radiodense, and glass foreign bodies as pocket-sized as 0.v to 2 mm can be detected easily on apparently radiographs.

TABLE ii

Signs of a Subconscious Foreign Body

Puncture wound

Blood-stained injury track of a fresh wound

Sharp pain with deep palpation over a puncture wound

Discoloration beneath the epidermis

Wound that elicits hurting with movement

Wound that fails to heal

Abscess (with sterile culture)

Hurting associated with a mass

Mass under the epidermis

Chronically draining purulent wound

Cyst

Granuloma formation

Sterile monoarticular arthritis

Periosteal reactions

Osteomyelitis

Pseudotumors of bone

Delayed tendon or nerve injury

On the other manus, wooden splinters are usually difficult to notice on plain radiographs unless in that location is paint on the wood that contains lead or other radiopaque substances.6 In most cases, ii radiographic views may be adequate, but an oblique view may be more revealing and is readily obtainable. Computed tomographic (CT) scanning and magnetic resonance imaging (MRI) detect many foreign bodies that may be missed on radiographs and are particularly helpful in detecting wooden splinters lodged near basic.7 Although wooden splinters may be visible at an early stage on a CT scan, they soon become isodense with the adjacent tissue every bit the wood absorbs h2o. Sonography provides an first-class alternative method for identifying and localizing radiolucent foreign bodies.8–13 A 7.5-MHz probe is used to search for small, superficial objects, whereas a 5.0-MHz probe is recommended for larger, deeper objects.

Splinter Removal

When possible, reactive objects should be removed earlier inflammation or infection occurs. Wood, thorns, spines, and other vegetative foreign bodies should exist eliminated immediately, simply drinking glass, metallic, and plastic tin be removed in a less restricted fourth dimension frame.13 Small elusive splinters may exist located more easily once they take become encapsulated by granulomatous or scar tissue.14

Proper preparation and setup include adequate lighting, anesthesia, magnification, and a bloodless, sterile field.4 The md must resist the temptation to remove the splinter past only pulling it out of the wound because this may leave pocket-sized fragments behind.

TABLE 3

Comparison of Diagnostic Tests for Detection of Foreign Bodies

Fabric	Manifestly radiographs	High-resolution ultrasound scans	Xeroradiographs	CT scans	MRI
Wood	Poor	Good	Superior to patently radiograph	Skillful	Good
Metal	Expert	Good	Good	Good	Poor
Glass	Skilful	Good	Good	Good	Good
Organic (thorns, spines)	Poor	Adept	Superior to plain radiograph	Practiced	Good
Plastic	Moderate		Superior to plain radiograph	Good	Good
Palm thorn	Poor	Moderate	Poor	Good	Adept

SUPERFICIAL HORIZONTAL SPLINTERS

Superficial horizontal splinters are by and large visible on inspection or easily palpated. The skin overlying the splinter is cleaned with povidone-iodine solution (Betadine) and infiltrated with 1 to 2 percent lidocaine with epinephrine (Xylocaine with epinephrine). Using a no. 15 scalpel blade, the skin is incised over the length of the long axis of the splinter, completely exposing information technology. The splinter is then hands lifted out with the blade or a forceps, and the track is cleaned with normal saline or povidone-iodine solution (Figure 1).

FIGURE ane.

Removal of a superficial horizontal splinter. Using a no. 15 scalpel blade, the peel is incised over the length of the long axis of the splinter, completely exposing information technology. The splinter is and then lifted out with the blade or a forceps.

Anesthesia may be spared for removal of a pocket-sized, superficial splinter. The splinter may be removed by picking information technology out with an 18-gauge needle, using calorie-free feathering strokes to de-roof the skin over the splinter.two Once the sliver is reached, information technology can be lifted out with the needle tip or with the aid of pocket-sized forceps. A firm pinching pressure applied to the local area reduces the amount of hurting the patient may feel and controls the bleeding.fifteen

Effigy ii.

Vertical splinter removal. A superficial incision is fabricated over the sliver, followed past deeper incisions, undermining both sides of the wound. The central block of contaminated tissue containing the splinter is and then excised with a deep elliptic incision effectually the wound entrance.

VERTICAL SPLINTERS

Splinters or foreign bodies such as needles that are at a right bending to the skin surface are normally more painful and hard to remove. After injection of local anesthesia and a povidone-iodine cleansing, a superficial incision is made over the splinter, followed past deeper incisions around the splinter, undermining both sides of the wound. This maneuver facilitates displacement of the splinter to the middle of the wound, where it is and then excised with a deep elliptic incision around the wound entrance ( Figure ii ).

DEEPER, ELUSIVE SPLINTERS

The search for a deeper, elusive splinter may exist difficult. Before searching for an elusive strange trunk, the md should set a fourth dimension limit for the search, ordinarily 20 to thirty minutes.xvi Subsequently this time, farther endeavor only increases the risk of tissue damage, and the likelihood of locating the foreign trunk is minimal. Blind autopsy with a curved hemostat is not recommended. Instead, an imaging technique should be used to help localize a deeper splinter.

Effigy iii.

Subungual splinter removal. A V-shaped slice of nail is cutting using modest, just strong, scissors and is removed using a nail elevator and a forceps. The splinter is grasped and removed, taking detail intendance not to push the splinter farther into the nail bed.

Radiolucent splinters are non visualized on patently radiographs, and CT scanning, MRI, or ultrasonography should exist strongly considered. Markers such every bit needles help in the precise localization of the splinter and facilitate its removal. Once localized, the foreign body is removed with a forceps or a hemostat, avoiding any unnecessary tissue dissection. Deeper splinters, especially those close to important structures such as nerves, tendons, blood vessels, or vital organs, should be referred for surgical removal.

SUBUNGUAL SPLINTERS

The traumatic introduction of wood splinters nether the fingernails and toenails is common and frequently associated with severe throbbing hurting.17 Well-nigh of the splinters are lodged in the distal portion of the blast and their removal does not result in smash dystrophy. However, for a more proximal subungual splinter, caution must be exercised not to disturb the nail matrix because this may result in failure of the boom to grow dorsum normally.

To remove such a splinter, the digit is anesthetized by means of a digital nerve block, and the nail plate overlying the splinter is partially avulsed. This can be accomplished by a diverseness of methods. Near commonly, a V-shaped piece of smash is cut using small, but strong, scissors. The indicate of the V is at the proximal tip of the splinter.17 The 5-shaped portion of the nail is removed using a smash elevator and a forceps. The splinter is grasped and removed, taking detail care not to push button the splinter farther into the nail bed ( Figure 3 ).

The smash plate also may be partially avulsed past shaving the blast plate overlying the splinter with a no. 15 blade. This is done past using light strokes with the blade held in a proximal-to-distal direction. This technique gradually creates a U-shaped defect in the nail, exposing the entire length of the splinter18 ( Figure iv ).

Alternatively, the distal portion of the nail plate may be vaporized with a carbon dioxide laser unit, if that option is bachelor.17

Effigy iv.

Subungual splinter removal. The nail plate overlying the splinter is shaved using a no. xv blade. Light strokes are used (in a proximal-to-distal direction), creating a U-shaped defect in the smash and exposing the unabridged length of the splinter.

Follow-Up Intendance

Later removal of the splinter, the wound is copiously irrigated nether loftier pressure, and the contaminated tissue is debrided.4 Sutures are avoided if possible, especially with contaminated wounds, where delayed primary closure is preferred. Routine wound-care instructions are given to the patient, and a 48-hour follow-up visit is scheduled as an function visit or a telephone call. Afterward subungual splinter removal, postoperative wound care should include an occlusive dressing and a topical antibiotic.

The demand for tetanus prophylaxis is addressed at the time of removal.2 Prophylactic antibiotics are generally not required but may exist considered in some cases, depending on the type of splinter fabric and the appearance of the skin and subcutaneous tissues.

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The Author

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CHRISTINA CHAN, M.D., is a physician in the family practice department at Saginaw Cooperative Hospitals, Saginaw, Mich., and a clinical instructor at Michigan State University College of Human Medicine, Section of Family Practice, East Lansing. She is a graduate of the American Academy of the Caribbean School of Medicine, St. Maarten....

GOHAR A. SALAM, M.D., D.O., is assistant director in the family do residency plan at Saginaw Cooperative Hospitals, where he performed his residency training. He is too assistant professor of family practice at Michigan Land University College of Human Medicine, E Lansing. He is a graduate of Dow Medical Higher, Karachi, Pakistan, and New York College of Osteopathic Medicine, Old Westbury, N.Y.

Address correspondence to Gohar A. Salam, Grand.D., D.O., 310 Hendrick Ave., Glen Cove, NY 11542 (electronic mail: goharsalam@yahoo.com). Reprints are not available from the authors.

The authors indicate that they exercise non have any conflicts of interest. Sources of funding: none reported.

REFERENCES

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1. Anderson MA, Newmeyer WL 3d, Kilgore ES Jr. Diagnosis and handling of retained foreign bodies in the hand. Am J Surg 1982;144:63–vii. ...

2. Buttaravoli PM, Stair TO. Minor emergencies: splinters to fractures. St. Louis: Mosby, 2000;471–seven.

3. Lammers RL . Soft tissue foreign bodies. Ann Emerg Med. 1988;17:1336–47.

4. Lammers RL, Magill T . Detection and management of foreign bodies in soft tissue. Emerg Med Clin N Am. 1992;10:767–81.

5. Smoot EC, Robson MC . Acute management of foreign body injuries of the hand. Ann Emerg Med. 1983;12:434–7.

6. Charney DB, Manzi JA, Turlik Thou, Young K . Nonmetallic foreign bodies in the pes: radiography versus xeroradiography. J Pes Surg. 1986;25:44–9.

7. Mizel MS, Steinmetz ND, Trepman E . Detection of wooden foreign bodies in muscle tissue: experimental comparing of computed tomography, magnetic resonance imaging, and ultrasonography. Foot Ankle Int. 1994;xv:437–43.

8. Shiels Nosotros 2d, Babcock DS, Wilson JL, Burch RA. Localization and guided removal of soft-tissue foreign bodies with sonography. AJR Am J Roentgenol 1990;155:1277–81.

9. Jacobson JA, Powell A, Craig JG, Bouffard JA, van Holsbeeck MT . Wooden foreign bodies in soft tissue: detection at US. Radiology. 1998;206:45–8.

10. Jacobson JA . Musculoskeletal sonography and MR imaging. A role for both imaging methods. Radiol Clin North Am. 1999;37:713–35.

xi. Bonatz E, Robbin ML, Weingold MA . Ultrasound for the diagnosis of retained splinters in the soft tissue of the manus. Am J Orthop. 1998;27:455–9.

12. Turner J, Wilde CH, Hughes KC, Meilstrup JW, Manders EK . Ultrasound-guided retrieval of modest foreign objects in subcutaneous tissue. Ann Emerg Med. 1997;29:731–iv.

13. Rudnitsky GS, Barnett RC. Soft tissue foreign torso removal. In: Roberts JR, Hedges JR, eds. Clinical procedures in emergency medicine. 3d ed. Philadelphia: Saunders, 1998:614–34.

14. Stein F . Foreign body injuries of the hand. Emerg Med Clin North Am. 1985;3:383–xc.

15. Bradley ET . Sprain, splinter, splint. Conn Med. 1991;55:175.

16. Pons PT. Foreign bodies. In: Rosen P, et al., eds. Emergency medicine: concepts and clinical practice. fourth ed. St. Louis: Mosby, 1998:861–77.

17. Miller MA, Brodell RT . Surgical pearl: treatment of subungual splinters. J Am Acad Dermatol. 1995;33: 667–eight.

xviii. Schwartz GR, Schwen SA . Subungual splinter removal. Am J Emerg Med. 1997;15:330–i.

This article is one in a series of "Office Procedures" manufactures coordinated by Thomas J. Zuber, M.D., Atlanta Medical Center, Atlanta, Georgia.

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