A 48-year-old surfer sustained a 1cm linear laceration to his anterior lower leg while surfing. The waves were 3-4 feet the water temperature was 58℉ (14℃), and turbid. The surfer stated he was surfing over a rocky bottom, bumped his leg against something, and continued surfing. Upon removing his wetsuit, he noted a small linear wound to his right lower leg which was bleeding. He rinsed the wound off in the shower and then place an adhesive dressing (Band-aid) over the wound. The wound had not fully healed after 3 weeks so he began applying Bacitracin ointment daily.
The patient presented for to an urgent care center medical care 6 weeks after the initial injury because the wound still hadn’t healed and had become raised and red.
Past Medical and Social History
No Medications. No Hx of diabetes. No Hx of peripheral vascular disease.
Allergic to Penicillin.
Non-smoker. Occasional Alcohol.
Review of Systems
No fevers or chills
Occasional clear-yellow wound discharge
Mild pain at site of wound
Physical Exam
Mell-appearing in no apparent distress. On the mid anterior right lower leg there was a 2.5x2cm raised erythematous, mildly tender wound. In the center of the wound there was a 1 cm area with a crusted scab that was not completely healed. Posterior tibial artery pulse and dorsalis pedis pulse normal. (See below)
Labs/X-ray
CBC: Normal ESR: Normal X-ray Tibia/Fibula: No foreign body seen, no signs of osteomyelitis
Patient was discharged on 10-day course of Doxycycline for possible marine acquired infection.
Patient Course
2 weeks later the wound had still not healed and appeared largely unchanged, so the patient went to an emergency department. An ultrasound was preformed showing a small foreign body (FB).
The location of the foreign body was marked on the skin surface. A 1 cm incision was made in order to explore the wound and remove the foregn body, but no foreign body was found.
The patient, now frustrated, sought the help of an interventional radiologist. Under direct U/S guidance, using a small “hockey-stick” ultrasound probe, the foreign body was again located. It was noted that there were, in fact, two small foreign bodies. An incision was made through intact skin just proximal to the wound. After 25 minutes of careful probing, a tiny foreign body which was black, and slightly flexible was removed. The exact composition of the FB was never determined. (see below)
Despite much continued probing, the second FB could not be removed. The wound closed very gradually over the next month.
4 weeks after foreign body removal and five months after the initial injury, the wound finally healed, although the overlying skin is still mildly raised and erythematous. A war wound that will not go away!
Discussion:
Lacerations are the most common surfing injuries presenting for medical care. The majority of lacerations are caused by impact from one’s own surfboard but many are caused by contact with the sea floor. This case illustrates a surfing injury with delayed healing of a small laceration caused by the presence of a radiolucent foreign body (FB). Clues that a foreign body might be present in a wound include the mechanism of injury, patient sensation of a FB, delayed wound healing, and wound infection. Wounds acquired while surfing may contain particles of sand, shell fragments, coral reef fragments, spines from marine animals, as well as other material. Wounds sustained by impacts from surfboard fins have been known to harbor fragments of fiberglass.
All acute traumatic wounds should be copiously irrigated and explored. If a FB is suspected, a plain x-ray is indicated. Most inorganic FB such as shells, glass, pebbles, metal and glass can be seen on plain films. If a FB is suspected but not seen on plain films it may be plastic, wood, thorn or other organic material which is radiolucent. Most superficial radiolucent objects such as those described above can be seen on U/S which most authorities recommend as the next imaging modality if plain films are normal and a FB is still a concern. CT and MRI are other modalities that are sensitive and give 3-d image of a foreign body but are expensive and rarely necessary.
While pre-tibial wounds are notoriously slow to heal because they are in a watershed area (poor vascular supply), a small wound to the lower leg in a healthy host should heal within 3 weeks. This wound had not healed after 2 months, including a 10-day course of Doxycycline, raising suspicion of a retained FB. Organic material embedded in a wound often results in delayed healing and local tissue inflammation as in this case, as well as local tissue destruction and infection. Infections cause by the presence of foreign body, are extremely resistant to treatment with antibiotics and require the removal of the foreign body before they will clear. Wound which fail to heal in an individual with no significant medical problems should raise significant concern for the presence of a FB, even if an initial x-ray is negative.