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| IMAGE QUIZ ARCHIVE | ||||||
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Image Quiz Pain, Swelling, and a Metatarsal Lesion1 (continued) | ||||||||||
| Because of the suspicion of an osteolytic tumor, an open biopsy was performed. The dorsomedial cortex was found to be destroyed and replaced by granulation tissue. In the cavity, a 2-cm-long black thorn was found and removed (Fig. 3). Before wound closure, the lesion was curetted, irrigated, and filled with a collagen sponge containing gentamicin sulfate. Pantoea agglomerans, an Enterobacter species commonly found in the soil, grew on cultures of parts of the thorn and the removed tissue. Histologically, chronic granulation tissue was found. | ||||||||||
 Fig. 3 | Photograph of the resected specimen, showing a black thorn and soft white granulation tissue. For larger view click on image |
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| A systemic antibiotic (ciprofloxacin) was administered for four weeks. The wound healed without complications. Upon retrospective review of the magnetic resonance imaging scans, we could identify the thorn (Fig. 2-C). | ||||||||||
| Discussion | ||||||||||
| Penetrating wounds of the foot are not uncommon. Many are caused by thorns or by fragments of wood that are retained in the foot, creating a foreign-body granuloma2. Symptomatic lesions may develop years after the injury, and the patient may not remember a specific injury event3. While chronic foreign-body reactions in soft tissues are quite common, penetrating injuries to the bone are rare4,5. | ||||||||||
| Only thirty-one cases of thorn, wood, or plant-splinter-induced lesions of bone have been reported in the English-language literature, to our knowledge. Because it is so exposed to injury, the hand is the most common location for thorns or splinters, with eight metacarpal lesions2,5-10 and two phalangeal lesions11,12 having been reported. The second most common location is the foot, with five metatarsal lesions13-17 and one cuneiform18, one cuboid17, and one phalangeal lesion10 having been reported. The median time from the injury to the detection of the osseous lesion was only four months, but the longest interval was twenty years, and seven patients could not recall any antecedent injury. The bone lesion that is induced by a thorn or a wood splinter usually appears to be a consequence of infection resulting in osteolysis or periostitis. Of the thirty-one reported cases, nineteen had osteolysis only; five, a periosteal reaction without osteolysis; and seven, a combination of the two. | ||||||||||
| In recent years, reports regarding the use of ultrasonography, magnetic resonance imaging, and computed tomographic scanning to facilitate the detection of foreign bodies have been published19-26. In general, splinters that have been soaked for more than a few days can be visualized with either computed tomography or magnetic resonance imaging, but the latter modality is preferred. Splinters that have been soaked for less than three days or those that are located near the bone are not detected reliably with any imaging method25. | ||||||||||
| The presence of a thorn or a wooden fragment in or adjacent to bone may induce not only a foreign-body reaction but also chronic osteolysis or, less commonly, a periosteal reaction of the bone. As these lesions occur most commonly in the distal aspect of the extremities, one should be aware of their characteristic clinical and radiographic patterns in the differential diagnosis of hand and foot tumors. Magnetic resonance imaging has proved to be a sensitive diagnostic method, especially in cases in which granulation tissue surrounds the foreign body. Treatment should include operative débridement and removal of the thorn, intraoperative culture, and administration of organism-specific antibiotics postoperatively. | ||||||||||
| References: | ||||||||||
1. Dürr HR, Stäbler A, Müller PE, Refior HJ. Thorn-induced pseudotumor of the metatarsal. J Bone Joint Surg Am. 2001;83:580-5. | ||||||||||
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