In September 2007, a 23-year-old man drank a six-pack of beer, had an argument with his girlfriend, and punched a plate-glass window with both fists. He sustained lacerations to his right arm. The man removed a large piece of glass from his arm, resulting in significant bleeding. He then wrapped a belt around his arm to stop the blood flow and went to the emergency department of the local hospital, where he was treated by Dr. S.

Dr. S. removed glass fragments from the patient’s arm, sutured it, and instructed him to follow up with his family physician in one to two weeks. When the patient saw another clinician, Dr. A., for suture removal, he reported worsening neurologic symptoms in his right arm. An appointment with an orthopedist was made, which the patient subsequently canceled.

About two months later, a retained glass fragment was removed by orthopedist Dr. R. The plaintiff alleged negligence by Dr. S. for his failure to remove all the glass fragments at the initial presentation. The plaintiff claimed that as a result he suffered a median nerve injury.

The defendant claimed that the nerve injury was most likely inflicted when the plaintiff removed the piece of glass himself before going to the hospital. The defendant also claimed that the plaintiff had been negligent in his failure to seek follow-up treatment as recommended. The defendant further maintained that the physician who removed the retained glass fragment had not determined it to be in the proximity of the median nerve.

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OUTCOME

A jury returned a verdict for the plaintiff that totaled $460,595. The defendant filed a motion for judgment notwithstanding the verdict and for a new trial. A confidential settlement was reached prior to a hearing on the motion.

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COMMENT

Patients and jurors expect foreign bodies to be discovered and removed with 100% precision. However, any clinician who has removed a foreign body knows that trying to locate one can be difficult under the best of circumstances.

Further, in cases in which a foreign body is not near a sensitive structure and is not likely to cause additional injury, removal may not be indicated (eg, retained bullet fragments not near a joint). In this case, the foreign body is glass and the location is described as the “arm,” which in all likelihood means the proximal forearm. So we have a potentially sharp item contained within a small space holding many sensitive structures.

Apparently, radiographs were not obtained. While some foreign bodies are radiolucent and generally considered “invisible,” glass is not necessarily one of them. There is a myth that glass is never visible on x-ray and another that glass is visible on x-ray only if there is sufficient “lead content” in it to make it so. Contrary to these beliefs, glass may be visible on standard x-ray, whether or not there is lead in it.

Here, it would have been reasonable to obtain radiographs to identify foreign bodies prior to closing the wound. The glass may have been visible and if detected, the emergency physician could have made a decision either to remove the glass or refer the patient if it was located deeply, next to a sensitive structure. Despite radiographic and physical exam findings, it is always important to remind patients that retained foreign bodies are possible and that follow-up is required. Schedule follow-up and document what the patient was told.

But what about foreign bodies that are almost always radiolucent on a standard film? Wood can be maddening: invisible on x-ray and hard to remove because unlike glass, metal, or stone, there is no confirming “scratch” or “clink” when wood is contacted with a localizing needle. Wood is also virtually guaranteed to suppurate if not removed.

Radiolucent or radiopaque is often considered an inherent quality of an object. But what is visible and what is invisible depends on radiographic technique. For foreign bodies generally considered radiolucent (eg, wood), consider a “soft-tissue technique,” which may demonstrate the foreign body, particularly if it is relatively large. While a positive image can be helpful, a negative one cannot rule out the presence of a foreign body. If available, ultrasound is also useful in detecting radiolucent foreign bodies and should be exploited by those skilled in its use.

In sum, jurors hate foreign bodies left in patients, be they items left in after surgery or not removed following an injury. Do your best, while explaining the limitations of removal efforts and the need for follow-up in complicated cases and self-monitoring in all cases. Instruct patients to return promptly for worsening signs and symptoms. Document that you informed the patient that 100% removal is never guaranteed and that they have agreed to return as scheduled or as needed. —DML

Why Punching a Window Is Never a Good Idea