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Three Part Question

In [patients with adequately explored superficial glass-caused wounds], is [screening radiography] necessary to [detect retained foreign bodies]?

Clinical Scenario

A 22 year-old female presents with lacerations on her hands after slipping and breaking a window with both hands. The wounds appear superficial on inspection. You wonder if these wounds can be adequately treated without the use of x-rays to rule out retained foreign bodies.

Search Strategy

Medline 1950-05/09 using OVID interface, PubMed clinical queries
[(*”glass”) AND (*Foreign bodies)]. Limit to human and English

Search Outcome

110 papers were found of which 3 were relevant to the three part question.

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
Avner et al. 1992 United States	226 children with lacerations due to glass occurring in a 21 month period presented to two pediatric emergency departments. Before x rays were obtained, the triage nurse or managing physician performed initial inspection and recorded whether the bottom of the wound was seen, presence of glass, and the length and depth of the wound.	Prospective, consecutive sample patient series.	Glass on x ray of wounds where bottom visualized	11/160 (6.9%)	The wounds were visually inspected prior to local anesthesia or wound exploration; therefore, the accuracy of wound exploration to exclude foreign body or adequately remove glass independent of x-rays was not determined. Also, 10 patients who were enrolled in the study were excluded from the results due to obvious glass in the wound. It is unclear if the glass in the wounds could have been adequately removed with exploration. In addition, their analysis of wound depth (superficial vs. deep) is inadequate to determine which wounds need x rays.
			Glass on x-rays where bottom of wound was not visualized	12/56 (21.4%)
			Wound depth associated with retained glass	0.76cm vs. 0.56cm (P<.05)
Steele et al. 1998 United States	164 adult patients with 185 glass-caused wounds who presented to the emergency department and consented to a radiograph. All patients underwent wound exploration, followed by x-rays, and a data sheet was completed by the examiner after exploration and x rays.	A prospective patient series	Wound exploration for foreign body	Positive Predictive Value 100%, Negative Predictive Value 95%	The study provides no follow-up information on the wounds with retained foreign bodies; thus, clinical significance is not determined. The authors do not provide the sensitivity and specificity of wound exploration to exclude foreign body. Sensitivity was 69% including ambiguous radiography reads. If these are assumed to be clinically insignificant, then the sensitivity becomes 82%. While the authors state that physicians believed the wound was adequately explored in 93% of cases, they do not determine the sensitivity of a negative wound exploration for a wound that was believed to be adequately explored by the examiner. Also, analysis of wound depth in relation to foreign body retention is not discussed.
Orlinsky et al. 2006 United States	167 adults and children who presented with glass-caused wounds to a large urban emergency department. X rays were take prior to clinical exam and not reviewed until the wound exploration was completed. Re-exploration for retained foreign bodies was performed as needed. Wounds were categorized according to depth, whether or not the clinician was able to adequately explore the wound, and whether or not a foreign body was found clinically. They number of foreign bodies in each wound was compared to the number removed during wound exploration, and wounds were classified as x ray beneficial or not.	A prospective patient series	x-ray beneficial superficial wounds	2/134 (1.5%) [0.2-5.3%] 95% Confidence	Follow-up was limited. No attempt was made to compare wound complications for wounds with no retained foreign body on x-ray to those with retained foreign body.
			x ray beneficial deep wounds	13/130 (7.7%) [2.7-11.8%] 95% Confidence

Comment(s)

Of the three studies found that addressed the question, the study by Orlinsky et al. was best designed to answer the question. Patients with superficial wounds (i.e. wounds that are no deeper than subcutaneous fat) have an overall decreased incidence of retained glass. Also, these wounds are easier to adequately explore to clinically exclude and/or remove retained glass. It is apparent from the three studies reviewed here, that deep wounds (ie. deeper than subcutaneous fat) need x rays to rule out retained glass as adequate exploration is diffucult and often inaccurate. Similarly, puncture wounds are difficult to explore and are more likely to have retained glass. These wounds likely need x rays to exclude retained glass. However, unnecessary use of emergency department resources can be avoided for superficial glass caused wounds that can be adequately explored by the treating physician. In the case of the retained, small, non-radiographically significant piece of glass, the clinical significance is unknown, but likely insignificant. A large randomized trail would be beneficial to determine if obtaining x rays in superficial wounds changes clinical outcomes such as infection rate, pain, etc.

Clinical Bottom Line

For patients with superficial glass-caused wounds, which can be completely visualized or probed on exploration, routine x rays are not necessary to exclude retained foreign body.

References

1. Avner et al. Lacerations Involving Glass. The role of routine roentgenograms American jounal of Diseases in Children 1992; 146 (5):600-2
2. Steele et al. Retained glass foreign bodies in wounds: predictive value of wound characteristics, patient perception, and wound exploration. American Journal of Emergency Medicine 1998;16(7):627-30
3. Orlinsky et al. The utility of routine x-rays in all glass-caused wounds The American Journal of Emergency Medicine 2006;24(2):233-6