Incomplete extraction of foreign body of thigh, a pitfall of low resource setting

surgery: A case report

Abstract
Key Clinical Message
Keywords:
Introduction
Case report
A 12-year-old male had a history of falling from a tree four months back. He sustained a
punctured injury over the medial aspect of the right thigh. For this complaint, his parents took
him to a nearby hospital, the gross foreign body was removed, and a further search was
performed to look for any remnant. After removing the foreign body, the wound was irrigated
with normal saline, dressed, and primarily sutured. The patient also received prophylactic tetanus
toxoid and antibiotics. After 15 days of the injury, the patient presented to the hospital with the
chief complaint of limping and persistent discharge from the sutured site. Due to the low
resource setting, the patient was referred to our tertiary center for further evaluation.
Although the patient was referred on the 15th day, they came to our center Emergency department
(ED) one month after the initial fall injury with the same chief complaints of limping and
persistent discharge from the wound site. At ED, ultrasonography of the wound site revealed a
foreign body and collections, and the patient was shifted to pediatric surgery for definitive
management.
Exploration was done, and the purulent collection was aspirated and sent for culture and
sensitivity. No apparent foreign body was found. However, the wound hasn't healed and has had
continuous purulent discharge since then. For increased limping gait and persistent discharge, an
MRI was done to locate the exact site of the foreign body and to catch the early stage of infection
that was not apparent in the X-ray(figure 1). MRI of the right thigh showed approximately
2.7x1.6 cm sized obliquely oriented T1/T2 low signal intensity foreign body noted in right groin
surrounded by T1/T2 high-intensity rim. T2 high intensity is noted over the muscle of the medial
compartment of the right thigh, including the adductor longus, brevis, obturator, and iliacus
muscle. No signal changes were noted in the femoral head and neck. The femoral head has
normal caliber. Heterogenous T2 high signal intensity collection is also noted in the
intermuscular and subcutaneous plane, which is traced to the exterior through skin defect in the
medial aspect of the groin. No abnormality was noted along neurovascular bundles (figure 2).
Due to the close location of the foreign body to the hip joint, increased limping, and
osteomyelitic changes on the right Iliac bone with the intermuscular and subcutaneous collection,
an orthopedic consultation was done, and the case was handed over to the orthopedic team.
On examination, the patient was afebrile with stable vitals. On local examination of the wound,
there was no induration and erythema surrounding the wound. The wound was 1 x 1 cm over the
medial aspect of the right thigh, discharging purulent discharge. There was a fixed flexion
deformity of 60 degrees, and on further flexion, the 60-to-120-degree movement could be
produced??? The range of motion on the sagittal plain was absent due to pain. The neurovascular
status of the right lower limb was within normal limits. The patient was kept on continuous skin
traction until the surgery. Swab c/s was along with CBC, ESR, hsCRP (……values…)
The orthopedics team did an exploration by the medial approach and found ….cm x…..cm
wooden material (figure 3). The foreign body was extracted, and the cavity was cleaned out. A
closed tube drain was kept. The wound was closed, and dressed.
Postoperatively, the patient was kept under continuous ROM exercise, abductor, and quadricep
strengthening. At discharge, the patient had improved ROM 10 degrees less than normal ROM.
At follow-up on 1 month, the patient remained asymptomatic with near the normal range of
motion.

Figure 1:
 Figure 2:

Figure 3:

Discussion

Conclusion
Acknowledgment
We, the authors, thank the patient for her support in publishing this paper.

Conflict of interests
None.

Funding
None.
Author contribution
Ethical approval
Our institution does not require ethical approval for reporting individual cases.

Consent statement
Written informed consent was obtained from the patient to publish this report in accordance with
the journal's patient consent policy.

Guarantor

References