Delayed diagnosis of foreign body

September 2006

Mr N attended his local A&E Department with cellulitis to the sole of his foot ten days after stepping on a stick. Radiographs did not reveal any foreign body and so he was prescribed antibiotics.

One week later Dr O, the consultant on duty, reviewed the case and explored the wound. Finding nothing, he explored the wound more fully two days later under general anaesthetic. He drained an abscess and took a biopsy.

Three weeks later the wound was healing well. However, two weeks after this Mr N presented with persistent inflammation. Dr O advised Mr N to return for weekly dressings. Further antibiotics were prescribed and arrangements made for regular review of the patient with a plan for further exploration if the ‘inflammation’ did not settle.

Three weeks later Mr N attended a different hospital where marked swelling was noted to the sole of the foot and a two-inch piece of wood was removed under local anaesthetic.

Mr N then brought a case against Dr O for negligence.

Expert opinion

A surgical expert felt that Dr O had made an attempt to identify the foreign body and had planned further exploration and was therefore not negligent. Locating radiolucent objects is difficult and surgical removal is not straightforward as the object can easily be missed in the soft tissues.

Dr O could not be blamed for not locating the object. The patient’s body had reacted to the splinter by the time he visited the second hospital, making it easier to find. The claim was successfully defended.

Learning points

• Always consider a retained foreign body in persistent soft tissue infections.  
• If the foreign body is radiolucent then localisation, ideally with ultrasound, should be performed routinely. This case occurred some years ago, in a location where ultrasound was not then available.  
• Where a doctor has followed good practice, MPS will not settle the case on grounds of expendiency. We believe that it is important to defend a professional's good reputation.

Further information

Gilsdorf JR, A Needle in the Sole of the Foot, Surg Gyn Obstr 163:573–574 (1986).
Combs et al, Orthopaedic Grand Rounds. Retained Wooden Foreign Body in the Foot  Detected by Computerised Tomography. Orthopedics (10):1434–5 (1986).
Graham DD jr, Ultrasound in the Emergency Department: Detection of Wooden Foreign Bodies in the Soft Tissues. J Emerg Med 22(1):75–9 (2002).