Medical Professional Publications

Embedded Foreign Bodies: New Challenges, New Solutions

William E. Shiels II, DO, Chairman, Department of Radiology, Nationwide Children’s Hospital

 

Over the past 15 years, radiologists at Nationwide Children’s Hospital have developed the leading international center of excellence for ultrasound diagnosis and minimally invasive, percutaneous ultrasound guided foreign body removal. Interventional radiologists have removed more than 600 foreign bodies from soft tissue, tendons, muscle and bone. Wood fragments, metal needles, glass, plastic pieces, graphite pencil tips, leaf and mulch fragments, and even crayon fragments have been removed with greater than 98 percent success. Using techniques developed at Nationwide Children’s, the interventional radiologists have removed these foreign bodies from the hands, arms, legs, feet, neck, face, chest wall and the orbit of patients ranging from 9 months to 54 years of age.

Image-guided foreign body removal (IGFBR) is safe, precise and effective in removing foreign bodies both visible and invisible to plain radiography and including those at risk for fragmentation during traditional operative removal techniques. Sonographically guided foreign body removal is performed through small incisions that leave little, or no scarring. X-ray and fluoroscopic guidance is adequate for metal and dense glass foreign bodies, but cannot detect wood, plastic, or other non-metallic foreign bodies. Sonography is able to detect all solid materials, including wood, leaf fragments, plastic, and crayon fragments.

Sonography provides real-time guidance for precise percutaneous removal of embedded foreign bodies. More than 1,000 radiologists from around the world have been trained in these unique foreign body removal techniques by interventional radiologists at Nationwide Children’s.

After 12 years of routine, and not so routine, removal of accidentally embedded foreign bodies, a keen medical student serving a Radiology research internship was assigned the foreign body project for review. As Adam Young scoured the data, he noted something unusual … some foreign bodies were “not accidental.” As Adam looked further, he found more cases of non-accidental, self-embedded foreign bodies that were removed by the radiologists. He brought his research findings to his faculty mentor with a detailed summary of locations, types of foreign bodies, and interesting behavioral health diagnoses … that were associated with the 11 “selfembedding” foreign body patients. As Adam and his mentor searched the world literature, there were no case series of this type of “self-embedding” behavior in the adolescent or pediatric literature. And now, in addition to being the leading center for percutaneous foreign body removal, Nationwide Children’s became the first center to identify adolescent behavior and injury patterns to be known as “Self-embedding Behavior” in adolescents. Self-injury, as a deliberate and direct destruction or alteration of body tissue without suicidal intent, is a relatively recent focus of scrutiny by the medical community. It is estimated that 3 million people in the United State choose to cut, burn or cause other types of intentional tissue destruction to their bodies. “Self-embedding” has now been officially recognized and defined as another form of self-mutilation that physicians should be made aware of when examining patients.

Accidental traumatic injury with retained soft tissue foreign bodies is common in primary care. However, self-embedding of foreign bodies is the result of self-injurious behavior in patients with complex behavioral health diagnoses. This specific behavior, Self-Embedding Behavior (SEB), is a new and unrecognized entity in the pediatric and adolescent medical literature. SEB has not been previously discussed in association with image-guided foreign body removal (IGFBR). Patients demonstrating SEB intentionally embed household objects (staples, pencil lead, unfolded paper clips, hairbrush teeth, comb teeth, crayon etc.) deep into the soft tissues in an act of self-harm. The behavior goes beyond conventional self-injury patterns, such as cutting and burning, and represents a unique form of self-injury.

SEB falls within the realm of self-injury as an attempt by the patient to affect intentional tissue injury for the purpose of transferring intense emotional pain to “more acceptable” physical pain. The relief is believed to be the result of release of endorphins following the self-harm; however, this temporary relief is typically followed by an addictive coping cycle of pain, relief, shame and self-hate. This is the likely explanation for the high percentage of repetition demonstrated in the SEB population. These patients are not to be confused with masochists who find pleasure in the self-inflicted pain, rather, the individual inflicting deliberate self-harm is seeking relief, and the sight and the warmth of blood often rejuvenates his or her sense of being alive. Furthermore, the self-embedding injury is not a suicide attempt; a person committing deliberate self-injury is, in fact, seeking a morbid form of self-help. Selfinjury can be considered a temporary solution to a permanent problem, as opposed to suicide, which is a permanent solution. This is not to say these patients are not at a higher risk for suicide, because it has been documented that selfinjury patients are 18 times more likely to commit accidental or intentional suicide.

SEB varies from traditional forms of self-injury due to a number of factors. Considering the unique patterns of injury, associated co-morbidity, and potential for repetitive behavior, SEB stands as a critical risk and requires heightened awareness from the medical community. First, all SEB patients (100%) in the Nationwide Children’s Hospital study presented with multiple co-morbid behavioral health diagnoses that are more severe than those seen with other forms of self-injury. Specifically, all patients were diagnosed with at least two of the following diagnoses: bipolar disorder, depression, post-traumatic stress disorder (from physical or sexual abuse), borderline personality disorder, anxiety disorder, and obsessive-compulsive disorder. Additional unique features of SEB include a high incidence in females (90%), high incidence of repetitive behavior (70%), and a high incidence of suicide association (90%). SEB patients in the Nationwide Children’s study ranged in age from 14 to18 years old, with an average age of 16 years old.

As noted previously, percutaneous radiological treatment (IGFBR) of self-inflicted foreign bodies is safe, precise and effective for foreign bodies that may be invisible to plain radiography. IGFBR was successful in 100 percent of SEB cases … 72 out of 72 cases of SEB foreign body removal. There have been no complications as a result of the IGFBR procedures; specifically no infections or injuries to vital structures such as nerves, tendons or vasculature. Furthermore, using this minimally invasive technique allows healing with little to no scarring which is very important for self-image and self-esteem in this high-risk patient population.

This report highlights the unique ability of primary care practitioners and radiologists to be the first to identify this behavior as the manifestation of a larger psychological disorder and need for intervention: a new role in public health and patient advocacy. This is an opportunity to raise the first red flag towards an appropriate diagnosis, and to rapidly mobilize the health care system (interdisciplinary team) for early and effective intervention and treatment, in order to interrupt the cycle of self-harm. The Nationwide Children’s study is the first report and the first to begin a Pediatrics and Public Health awareness campaign to emphasize interdisciplinary (pediatrics, pediatric emergency medicine, pediatric radiology, adolescent health, and behavioral health) care of these teenagers for effective, complete therapy, and prevention of repetitive injury patterns and complications from future episodes. Left untreated, complications include abscess formation, vascular injury, nerve injury, bone infection, and worsening of current psychological disorders. Understanding SEB affords primary care practitioners and radiologists a unique role as part of an interdisciplinary team to provide the first diagnosis, percutaneous treatment, and rapid mobilization of behavioral health therapy to interrupt the cycle of self-harm and help these teenagers find coping skills that translate into a healthy adult life. Learn more about Interventional Radiology at www. NationwideChildrens.org/Radiology.

References:

  1. Young AS, Shiels WE, Murakami JW, Coley BD, Hogan MJ. Self- Embedding Behavior: Radiological Management of Self-Inflicted Soft Tissue Foreign Bodies. 2009 Radiology, in press.
  2. Favazza AR. The coming of age of self-mutilation. The Journal of Nervous and Mental Disease 1998; 186 (5): 259-268.
  3. Briere J. Self-mutilation in clinical and general population samples: Prevalence, correlates, and functions. American Journal of Orthopsychiatry 1998; 68(4): 609-620.
  4. Jacobson CM, Gould M. The Epidemiology and Phenomenology of Non-Suicidal Self-Injurious Behavior Among Adolescents: A Critical Review of the Literature. Archives of Suicide Research 2007; 11(2): 129-147.
  5. Shiels WE, Babcock DS, Wilson JL, Burch RA. Localization and guided removal of soft-tissue foreign bodies with sonography. American Journal of Roentgenology 1990; 155 (6): 1277-1281.
  6. Shiels WE. Soft Tissue Foreign Bodies: Sonographic diagnosis and therapeutic management. Ultrasound Clinics of North America 2007; 2 (4): 669-681.
  7. Hicks KM, Hinck SM. Concept analysis of self-mutilation. Journal of Advance Nursing 2008; 64 (4): 408-413. 
  8. Nock, M. Why Do People Hurt Themselves?: New Insights Into the Nature and Functions of Self-Injury. Current Directions in Psychological Science 2009; 18 (2): 78-83.
  9. Clarke L, Whittaker M. Self-mutilation: culture, contexts and nursing response. Journal of Clinical Nursing 1998; 7 (2): 129–137.


SEB Case Study

It was a beautiful crisp morning in December as James W. Murakami, MD, MS, (a pediatric radiologist at Nationwide Children’s Hospital) reviewed the scheduled cases for the day in Interventional Radiology: “PICC line placement, PICC line placement, G-J tube replacement, neck mass biopsy, abscess drainage, sclerotherapy, bronchial artery embolization and foreign body removal.” These cases were nothing too far out of the ordinary at Nationwide Children’s, or so he thought. As Dr. Murakami proceeded through the morning, he “PICC’d” away at the schedule and the next case was a 15 year old girl, in for foreign body removal. Dr. Murakami was thinking this would be no big deal, and she would probably be a routine #605 of the hundreds of foreign bodies removed with interventional radiological techniques at Nationwide Children’s. But this was a little different … she was a patient he knew from before … and had not one, but four, foreign bodies in the forearm. Reviewing the x-ray from the emergency department, she had two metal staples and two linear foreign objects with radiographic density that looked like graphite pencil lead in her forearm. “OK, he thought, more Lidocaine, a little more time, and I’ll remove these like I did the last time she was here for foreign body removal.” Sedation is underway, the patient is resting, and Dr. Murakami interrogates the forearm with ultrasound … two metal staples, two graphite pencil tips, and ….more….three, five, eight, now … 11 more foreign bodies in the forearm! More sedation, more precise work navigating between veins, arteries, nerves, tendons and muscle … with three, 5 mm incisions. (See Forearm Illustration, Figure 1.) All 15 of the foreign bodies were successfully removed. As Dr. Murakami placed the small dressings on the 3 incision sites, the 15 year old patient turned to him and announced, “I think the next time … I want to be completely asleep with anesthesia.” Dr. Murakami looked, pensively trying to be most diplomatic with his response, and said in return “Let’s not have ANOTHER time.” (Image at left shows Dr. Shiels holding unfolded paperclip removed from patient’s arm).

 


Figure 1: Illustration of foreign bodies in arm



Bio

William E. Shiels II, DO, chairman, Department of Radiology, Nationwide Children’s Hospital and president of the The Children’s Radiological Institute. Dr. Shiels is a clinical professor of Radiology, pediatrics, and Biomedical Engineering at the Ohio State University College of Medicine. Dr. Shiels is a clinical professor of Radiology at The University of Toledo Medical College and Visiting Scientist at the Armed Forces Institute of Pathology, Washington, DC.

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