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Bahrain Medical Bulletin, Volume 22, Number 2, June 2000

Retained Snail SheII in the Foot

Freih Odeh Abu Hassan, FRCS E, FRCS(Tr. & Orth;*

A 50 year old mate, presented with a painfut swetling of his forefoot due to getained snail shell causingClostridial and Pseudomonas infection. There is'ho report of such a case iii'the literature.

Bahrain Med BuIt 20(M;22(2):86-87-.-..:

Retained fofeign bodies in the foot are seen frequentlybut as far as we know a snail shell in the foot has notbeen mentioned in the literature. We report this case ofa missed unusual foreign body in the foot in order todraw attention to the need for plain x-ray of the foot inany puncture wound.

TIIE CASE

A 50 year old engineer presented to the orthopaedicclinic with marked swelling and a puncturg wound onthe plantar aspect of the forefoot. He gave history oftrauma while running on the beach. The patientconsulted the nearby hospital where cleaning of thewound was done and oral antibiotics were prescribed.He was referred to the clinic after 3 days.

on examination, he had low grade temperature andlocally there was marked swelling of the forefootassociated with redness and signs of lymphangitis.There was a 1 cm puncture wound on the plantar surfaceof the right forefoot with minimal purulent discharge.Plain x-ray of his foot showed an unusual foreign body(Snail shell) at the level of the first metatarsal (Frg 1).There were no signs of any bony injuries.

The foreign body was removed under generalanaesthesia (Fig 2). The wound was irrigated withnormal saline and kept open.

Figure 2. The snail Shell

The patient was given Penicillin initially but when theculture later revealed Pseudomonas species andClostridia perfringes Gentamycin was added for 5 days.Follow up of the patient did not reveal any signs ofresidual infection.

DISCUSSION

Retained foreign bodies in the foot are cofirmonly due toneedles, but abnormal foreign bodies have been reportedin the form of cocktail stickl, Sea urchin spines2,stingray spine3, sponge rubbe{, pieces of woods, Piluscuniculafus6, radiolucent foreign body7, metallic foreignbodys and graphite foreign bodye.

Diagnosis of retained foreign bodies depends on a highdegree of suspicion, full clinical examination and historyof the exact mechanism of injury and whether there wasa puncture wound or not. Sometimes, a plain x-ray isnot sufficient for confirmation of the presence of theforeign body. Some doctors went on to use theultrasound to detect the radiolucent foreign bodies like

Figure I. X-ray showingmetatarsal

shell a,t the level of the firstsnail

* Assistant clinical Professor of OrthopaedicsUniversity of JordanAmmanJordan

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'Bahrain Medical Bulletin, Volume 22, Number 2, Ju:ne 2000

glass or woodlo,ll. Others did CT Scan to localize

undiagnosed retained foreign bodiesl2-l4.

The usual trend for treatment of symptomatic retained

foreign bodies is their removal under general anaesthesia

using Tourniquet and a flouroscop-y. However, most of,

us do encounter asymptomatic broken needles in the

foot which if removed causes more damagp than benefit

to the patient. Some surgeons even suggest non

operative treatment for retained radiolucent foreign

bodies by application of a cast especially after failure ofthe initial exploration as these foreign bodies willeventually extnrdels.

The complications of retained foreign bodies include

osteomyelitis, septic arthritis, periosteal reaction,pseudo tumors and osteomyelitis like lesionsl6-18.

Our case did cause Pseudomonas and Clostridialinfection of the soft tissues of the foot.

CONCLUSION

Retained foreign bodies in the foot are quite common

and are usually missed especially if they areradiolucenl The diagnosis usually depends on a highdegree of suspicion and proper clinical examination.Plain x-ray is satisfactory for radio-opaque foreignbodies, but for radiolucent bodies an ultrasound isrecommended.

Our case of retained snail shell in the foot is anotherextremely unusual case which has not been reportedbefore and can be added to the list of unusual foreignbodies in the foot.

REFERENCES

1. Rand C. Coctail stick injuries: Delayed diagnosis of a

retained foreign body. Br Med J 1987; 295: 1658.

2. Falkenberg P. Sea Urchin spines as foreign bodies -An

alternative treatment. Injury : Br J Accid Surg

1985; 1,6:419-20:"

3. Moyles BG, Wilson RC. ,stingray spine foreign body in

the foot. J Foot Surg 1989;28:30-2.

4. James SW Raliegh NC. Unusual foreign body secondary

to nail injury.Arch Dermatol 1975;trI:1.

5. Cracchiolo A. Wooden foreign bodies in the foot, Am J

Surg 1980;140:585- 7.

6. Ronnen M. Pilus Cuniculatus, Induced Cellulitis of the

foot due to puncture with bristle Hair. Int J Dermatol

1986;25:387-8. 7

7. Richmond PW. Williams LA. Glass in the foot :

Negligence or a criminal act. Br Med J 1989;298:1491.

8. Meyer WG. Metallic foreign bodies in the sole of the foot.

Ohio state Medical Journal 1969;65:906-7.

9. Masters SS. Graphite foreign body. A case Report. J Am

Podiatr Med Assoc 1969;59:52.

10. Gooding. Sonography of the hand and foot in foreign body

detection. J Ultrasound Med 1987;6:4I-7.1 1. Kobs. A retained wooden foreign body in the foot detected

by ultrasonography. A Case Rpport. J Bone Joint Surg

1992;74:296-8.12. Goldenberg RA. Needle localization of foreign bodies

using computed tomography: A Case Report. JAm Podiatr

Med Assoc 1988;78 :629-31.

13. Combs. Retained Wooden foreign bodies in the footdetected by CT, Orthopaedics 1986;9:L434-5.

14. Nyska M. The advantage of CT in locating foreign body inthe foot. J Trauma 1986;26:93-5.

15. Huuiman WW, Bhuller GS. Non Operative Treatment ofRetained Radiolucent Foreign Bodies in Lower Limbs. J

Pediatr Orttrop 1 982;2:506-8.16. Greena WB. Unrecognized foreign body as a focus for

delayed serratia Marcescens Osteomyelitis septic arthritis.

J Bone Joint Surg 1989;7L:754-7

17. Kleiman. Periosteal reaction due to foreign body induced

inflammation of soft tissue. Pediatrics L977;60:63841.

18. Swischuk. Wooden splinter induced pseudo tumors &osteomyelitis like lesions of bone and soft tissue. Am JRoentgenol, Radium Therapy & Nuclear Med1974'L22:176-9.

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