Management of Foreign Bodies in the Soft Tissue of the Hand

Diagnostic Approach

The American College of Radiology recommends radiographs of the area of interest as the appropriate first imaging study for suspected foreign bodies in the hand or wrist, with multiple views to maximize detection of radiopaque foreign bodies 1, 2
Ultrasound (US) is the preferred imaging modality when radiographs are negative but foreign body is still suspected, with a reported sensitivity of 95% for foreign body detection, and can characterize foreign body morphology, depth, and relationship to adjacent structures 2, 3
US can detect foreign bodies with some degree of posterior acoustic shadowing, and all foreign bodies appear hyperechoic on US 3
CT without IV contrast is an equivalent alternative to US, with high sensitivity for detection of radiopaque foreign bodies, and is superior to MRI for identifying water-rich fresh wood 1, 2

Ultrasound has limitations, including reduced effectiveness for foreign bodies deeper than 4cm from skin, difficult visualization if air is present in adjacent soft tissues, and cannot detect foreign bodies within bone 3
MRI has limitations, including lower sensitivity compared to CT and US for foreign body detection, potential risk with metallic foreign bodies due to magnetic field interaction, and radiographic screening for metallic foreign bodies is recommended before MRI 1, 3

Hand surgeons should be consulted due to the risk of damage to tendons, nerves, and blood vessels during removal, and potential for infection, inflammation, and functional impairment if not properly managed 3
Surgical exploration is necessary when the foreign body is adjacent to critical structures, or embedded in bone, and US-guided removal can be considered as a first-line treatment procedure 3
Tendon or nerve injury may result from the foreign body or during removal, and chronic inflammation and infection can develop even months after the initial injury 3