Tag Archives: foreign body

Retained foreign body in the foot presenting as tenosynovitis of the flexor digitorum longus tendon

by Muhammad Haseeb¹, Muhammad Farooq Butt², Khurshid Ahmad Bhat³

The Foot and Ankle Online Journal 10 (1): 2

Tenosynovitis of the foot and ankle is an uncommon condition, and may stem from several causes resulting in foot/ankle pain. Additionally, infectious tenosynovitis resulting from retained foreign bodies distant from the tendon is rarely reported. In this paper we report a case of a young male presenting with a short history of swelling and pain of the ankle. Clinical examination suggested tenosynovitis of the flexor digitorum longus tendon. There were no systemic symptoms and blood parameters within normal limits. Non-response to conservative treatment prompted imaging of the foot which revealed a foreign body, which had been lying there for many years and forgotten about by the patient. The patient underwent removal of foreign body and made a complete recovery. Foreign bodies can be difficult to diagnose and should be considered in the differential diagnosis of unexplained pain, even in the absence of recalled trauma. Puncture wounds of the foot through rubber soled sandals or shoes have been described to leave behind pieces of the sole material as foreign bodies. Ultrasonography is particularly helpful in confirming such diagnoses.

Keywords Foreign body, tenosynovitis, ultrasonography, sole

ISSN 1941-6806
doi: 10.3827/faoj.2017.1001.0002

1 – Registrar, Department of Orthopaedics Government Medical College, Jammu, India
2 – Lecturer, Department of Orthopaedics Government Medical College, Jammu, India
3 – Registrar, Department of Orthopaedics Government Medical College, Jammu, India
* – Corresponding author: quicksilver.hsb@gmail.com


oot and ankle pain is one of the common complaints with which patients present in an orthopaedic clinic. Non-traumatic foot and ankle pain stems from a wide variety of causes which need to be excluded by detailed history and clinical examination to arrive at a correct diagnosis and institute effective treatment. Tenosynovitis is a relatively uncommon entity causing foot and ankle pain and most cases have a specific etiology for the condition. We present the case of a young patient who had tenosynovitis of the flexor digitorum longus that remained unresponsive to treatment for a long time because the etiology could not be established.

Case Report

A 20-year-old male presented in the clinic in January 2016 with a history of pain and swelling just proximal to the medial aspect of the right ankle of one month duration. Examination revealed a soft to fluctuant swelling behind the medial malleolus merging imperceptibly with the soft tissue of the calf above and the foot below. The swelling was tender with some mobility in a side to side direction. The pain increased with movement of the toes. There was no history of fever, joint pains or stiffness, trauma to the ankle, or any significant drug history.  A clinical diagnosis of tenosynovitis was made and the patient was prescribed anti-inflammatory medication and cold compresses. Blood parameters were ordered at the same time.  The total leukocyte count was  8500/mm3. ESR was 12mm and CRP was low positive. Serology for rheumatoid arthritis was negative.  Symptomatic treatment and physical therapy was continued but the patient did not improve. Over a period of one month the symptoms worsened. Plain radiographs were normal. An MRI was ordered and a local steroid injection of the tendon sheath was planned. MRI showed tenosynovitis of the flexor digitorum longus (FDL) tendon with collection in the tendon sheath at the ankle. At the time of steroid injection, initial aspiration yielded pus. Injection was abandoned, and the pus was sent for culture and sensitivities. Possible causes of pyogenic tenosynovitis were sought. The patient was asked again about any penetrating injuries in the region. He recalled a penetrating wound in the sole (from a nail) that he had suffered 4 years back, which had healed uneventfully. Present examination of the sole was normal. An ultrasonography of the foot and ankle was ordered. Ultrasound revealed an echogenic foreign body in the midsole at a depth of about 1 cm from the skin surface, and about 3 mm in each dimension (Figure 1). Fluid collection was also found behind the medial malleolus, extending into the subcutaneous tissue.

Figure 1 Ultrasonographic image showing the foreign body.

Surgery was planned and two incisions were made. The incision in the sole at the site marked by the sonologist   revealed a red rubber foreign body, about 3 mm by 2 mm inside a loculus of pus (Figure 2). Another incision made behind the medial malleolus was used to drain the pus in the FDL tendon sheath and the surrounding tissue. The foreign body was a piece from the slipper sole that the nail had pushed inside. At that time, treatment with antibiotics and analgesics had probably resulted in healing of the wound, and the foreign body had become walled off. Now infection had reactivated and pus had travelled up along the sheath of the FDL, presenting as swelling at the ankle. Following incision and drainage, and administration of culture specific antibiotics, the wounds healed uneventfully and the patient had complete resolution of symptoms. He was asymptomatic at the time of last follow up, at eight months after surgery (Figure 3).

Figure 2 Note the red piece of rubber found on exploration of the plantar foot.

Figure 3 Complete healing of both wounds at eight month follow-up.


An Australian study concluded that almost 1 in 5 people in the community suffer from foot and ankle pain of nontraumatic origin [1].  Cases of nontraumatic foot and ankle pain are relatively frequent in our practice as well. Effective treatment of these cases depends on establishment of a diagnosis by accurate history and clinical examination, along with investigations and imaging. Among the common causes of such presentations are tendinitis, tendon rupture, bone spurs, bursitis, flatfeet, infections, rheumatoid arthritis and gout [2].

Our patient was a young and healthy male, with a relatively short duration of symptoms. In the absence of any fever or systemic signs, infection was not high up among our differential diagnoses. We ruled out inflammatory arthritis with clinical findings, serology and blood parameters. Some drugs like fluoroquinolones have been reported to cause tenosynovitis [3], but our patient had no significant drug history.

Foreign bodies can be difficult to diagnose and should be considered in the differential diagnosis of unexplained pain, even in the absence of recalled trauma[4]. If there is no recent history of trauma (skin puncture), and if the foreign body is radiolucent, the diagnosis is often difficult with plain radiographs [5,6]. Such foreign bodies can present later with a myriad of manifestations like local abscess, persistent pain, periostitis, osteomyelitis, bursitis, monoarthritis, synovitis, lytic lesions and even appear as neoplasms [4,6-9]. Even though MRI is very informative about soft tissue conditions of the foot, ultrasonography has now become the investigation of choice in diagnosing and locating retained foreign bodies in the extremities when they are radiolucent [10,11,12]. Harris [5] reported the misinterpretation of MRI, and final diagnosis with the help of ultrasonography, as in our case.

Puncture wounds of the foot through rubber soled sandals or shoes have been described to leave behind pieces of the sole material as foreign bodies [13,14]. A high index of suspicion is required when the patient presents late after the initial injury and does not volunteer information about the puncture wound. This is especially important in a case like ours where the area of presentation (distal leg) was away from the region of the puncture (plantar foot).

To conclude, even in the absence of a recent history of penetrating trauma, the possibility of a foreign body must be considered and investigated. Our case is unique because of the long duration between the injury and the presentation, and also the peculiar presentation of tenosynovitis above the ankle when the offending agent was present in the plantar foot. We further affirm that ultrasonography can be alternate imaging technique after plain radiography for all patients with suspected foreign bodies.


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The Role of High Resolution Ultrasonography in Detection of Neglected or Missed Radiolucent Foreign Body in Foot and Ankle Region

by Reyaz Ahmad Dar (MS)1emailsm, Mubashir Maqbool Wani (MS)2emailsm, pdflrgMubashir Rashid Beig (MS)1, Muzaffer Ahmad Ganaie (MS)1

The Foot and Ankle Online Journal 6 (3): 2

A prospective case series was undertaken to assess the role of high resolution ultrasonography to detect radiolucent foreign bodies in the foot and ankle region. Out of 30 suspected foreign bodies, ultrasonography was able to detect 28 foreign bodies with 2 false negatives. The overall sensitivity was 93.33%. The false negatives were attributed to the foreign body being obscured by bone.

Key words: , foot, ankle, ultrasound,

Accepted: February, 2012
Published: March, 2013

ISSN 1941-6806
doi: 10.3827/faoj.2013.0603.002

Address correspondence to: Department of orthopaedics, SKIMS Medical college Srinagar Kashmir India – Pin 190018

1Department of orthopaedics, SKIMS Medical college Srinagar Kashmir India – Pin 190018
2Hospital for bone and joint surgery Barzulla Srinagar Kashmir India – Pin 190005

Missed or neglected foreign body and subsequent complications in the extremities is a challenging complaint in the orthopedic outpatient department. Most of these cases present with soft tissue mass, granuloma, abscess, corns, osteomyelitis, fasciitis, cellulitis, chronic discharging sinus, and tendon contracture with or without pain.[1,2,3] The initial investigation is usually done with a plain radiograph, which however, cannot detect radiolucent foreign bodies such as those of wood, plastic and rubber.

Of the other imaging modalities, xeroradiography provides better edge enhancement, but it requires special equipment and is inadequate in detecting radiolucent foreign bodies.[4,5]

Computerized tomographic (CT) scan has the ability to detect the radiolucent foreign bodies with limitations of ionizing radiation, cost and poor sensitivity in detecting small foreign bodies.[6,7] Magnetic Resonance Imaging (MRI) can detect radiolucent foreign bodies but has the limitations of being inaccessible, expensive, and a concern regarding magnetic foreign bodies as well as time consuming.


Figure 1 and Figure 2 High-resolution ultrasound of a foot suspected of having a foreign body.

There is an added disadvantage of not detecting foreign bodies with low signal intensity from tissues such as scar tissue, tendon and calcifications.[8,9] Sonography, on the other hand, is easily accessible, inexpensive and a time saving image modality.

We undertook our study on thirty patients who presented to our outpatient department at two hospitals with a definite history of foreign body injury to the foot and ankle region. Patients presented with varied signs and symptoms which included pain, soft tissue mass, abscess, corn, chronic discharging sinus with duration of symptoms ranging from four months to eight years.

Most of these patients were initially managed by primary care givers and missed or often self treated themselves removing only a part of foreign body and subsequently neglected. Our aim was to assess the role of foreign body detection in these patients with high resolution ultra sonography (USG).

Materials and Methods

Thirty symptomatic patients who had a definite history of foreign body injury of the foot and ankle region were included in this study. The symptoms of these patients varied from simple pain to chronic discharging sinus and all had a normal plain radiograph. All of them underwent high resolution ultra sonography of the affected part followed by surgical exploration.

Sonography was conducted by four specialist doctors who had a minimum of four years of experience in the radiology department. Sensitivity of USG was determined with respect to that found on surgical exploration.


Thirty consecutive patients presented to our outpatient departments from May 2008 to May 2012 with history of foreign body injury. Patients presented with persistent pain, soft tissue mass, granuloma, abscess or chronic discharging sinus with a normal radiograph. Nineteen patients were male. Twenty two patients were younger than twenty years of age. Twenty eight patients had symptoms in the foot; two had symptoms in the ankle region. Twenty three patients had a history of nail insertion in the foot through a rubber sole. There was thorn injury in six patients with five having it in the foot and one in the ankle region. One patient had injury to the ankle with a wood. Three patients had multiple surgical interventions for chronic discharging sinuses.

All these patients were sent to radiology for the high resolution ultra sonography of the affected part. In all our cases a frequency of 7.5 MHz to 13 MHz was employed. Foreign bodies were reported as hyperechoic masses with surrounding hypo echoic rim with an acoustic shadow in twenty eight patients (Fig. 1 and Fig. 2).


Figure 3 Foreign body seen at the time of surgery.

Two patients which were reported negative had chronic discharging sinus with one having it on the lateral malleolus and another on the dorsal aspect of the foot. All patients underwent surgical exploration under general or regional anaesthesia with tourniquet control. Preoperative methylene blue injection into the sinus was used in three patients with chronic discharging sinus. Foreign bodies were recovered from all the patients (Fig. 3 and Fig. 4). Two patients who were labeled by the sonologist of not having a foreign body had foreign bodies close to or obscured by the bone. One of the patients had injury to the right lateral malleolar area with a wooden foreign body with persistent sinus discharge, and on exploration the foreign body was found very close to and abutting the cortex. Another patient had a history of nail insertion through the sole of the shoe with persistent sinus discharge on the planter aspect of the foot, and on surgical exploration a piece of rubber was found abutting the second metatarsal shaft cortex on the dorsal aspect. Out of the total thirty suspected radiolucent foreign bodies, high resolution ultra sonography was able to detect the foreign body in 28 patients with two false negatives with an overall sensitivity of 93.33%.


Figure 4 Foreign body after removal.


The basic principle of ultra sound is the use of a transducer to penetrate tissues with ultrasonic waves at various frequencies. When the wave strikes the denser component of tissue, they bounce (echo) back to the transducer. The ultrasound can then interpret the speed and intensity of the sound wave to determine the location and composition of the object. Structures are plotted on the screen based on their depth and location relative to the transducer. Superficial structures are plotted at the top and deeper ones at the bottom of the screen. The larger the surface area toward the transducer the greater it will reflect. Sonographic features of the foreign bodies in the soft tissues have three components. Firstly, the appearance of the foreign body; secondly, the changes in the soft tissues surrounding the foreign bodies. Thirdly, the appearance of soft tissues distal to the foreign bodies.

All foreign bodies on ultrasonography appear as hyperechoic foci. The reflectivity depends on acoustic impedance of the foreign body which in turn varies with the density of the object. In general, metal, mineral, glass, wood, and rubber reflect sound, appearing white on the screen. The changes surrounding the foreign bodies are due to inflammatory reaction which may range from edema to abscess formation.

This reaction takes some time to develop and is shown as hypo echoic rim around the foreign body. Distal to the echo rich foreign body acoustic shadowing is noted. This is due to failure of the ultrasound to pass through the foreign body.[10,11]

Despite their size, foreign bodies are no small matter. When left untreated they cause pain, swelling, infection, nerve and tendon injury.[2,3,12] Although USG has been a well-established diagnostic tool for foreign bodies in the soft tissues, it has been underutilized in this part of the world. While evaluating the usefulness of USG in the detection of unsuspected foreign bodies followed by CT, MRI, bone and labeled red cell Scintigraphy, it has been found that the later investigations added no relevant information and were time consuming and costly.[12] The sensitivity of USG in detecting different foreign bodies has been reported to be 70% to 100%. Cases which turned out to be false negatives had either a very deep foreign body, gas around foreign body, or a foreign body too close to the bone [8,13,14,15] as was the case in two of our patients.

Several studies have demonstrated the effectiveness of USG in detecting non-opaque foreign bodies in the soft tissues. The power of USG is as important as the depth of penetration of wave into soft tissues. The shorter wave length with high frequency penetrates less as most of energy is absorbed by the medium.[15] The authors do not believe that the results could be different if the USG was done by the same radiologists. Differences in the comparative accuracy, sensitivity and specificity of foreign body detection by radiologist and USG technician has not been found to be statistically significant in the previous studies.[16]


The authors do not recommend replacing plain radiography with ultrasonography in the evaluation of suspected foreign bodies of the foot and ankle region. But Sonography should definitely be considered part of diagnostic work up of patients in whom we strongly suspect the presence of radiolucent foreign bodies based on history and symptomatology.


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