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Dr. Rajendran Rajendran
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1) A 28-year-old man presents to the emergency with a right forearm laceration that he sustained from a piece of glass during a fight. He complains of pain at the laceration site but denies a foreign body sensation. On examination, the laceration is superficial and 4 cm long. The patient demonstrates intact strength and sensation distally. Which of the following statements regarding imaging this patient is true?

a. Imaging can be omitted because he does not have a foreign body sensation.

b. Imaging is not indicated because retained glass does not cause an inflammatory reaction.

c. Plain film is the next best step in the management of this patient.

d. CT scan is the most commonly used modality to rule out a foreign body.

e. Plain film cannot rule out bone, teeth, or glass in soft tissue.

Ans: (c)

80% to 90% of foreign bodies can be seen on plain films. Glass > 2 mm is visible on plain film. Plain film can usually locate metal, bone, teeth, pencil graphite, gravel, sand, and aluminium. Plain film cannot detect wood, thorns, some plastics, and other organic matter. CT is capable of detecting more types of foreign bodies than plain film but it is not commonly used given the time needed and expense.

Lack of a foreign body sensation cannot be used to rule out a foreign body.

Retained foreign bodies may lead to a local inflammatory response or to local and systemic infection.

2) A 38-year-old man presents to the emergency with a left foot puncture wound from stepping on a rusty nail. His last tetanus vaccine was during childhood, which resulted in a severe allergic reaction and a prolonged hospital stay. Which of the following is true regarding tetanus immunization in this patient?

a. Give tetanus toxoid.

b. Give tetanus immunoglobulin.

c. Give tetanus immunoglobulin and toxoid.

d. Give neither tetanus toxoid nor immunoglobulin since he has had an allergic reaction in the past.

e. Give tetanus toxoid and immunoglobulin with diphenhydramine.

Ans: (b)

Tetanus toxoid is contraindicated in patients who have had a severe allergic reaction including respiratory distress or cardiovascular collapse. Tetanus immunoglobulin can be used in these patients. Local reaction at injection site resulting in redness, pain and swelling is not considered a contraindication.
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