11.06 Superficial Sliver
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agk's Library of Common Simple Emergencies

Presentation
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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:
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- 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 neuro- 
    vascular 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
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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.

Illustration
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img/cse1106.gif

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 from Buttaravoli & Stair: COMMON SIMPLE EMERGENCIES
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