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Foreign body granuloma and synovitis of the finger: A hazard of ring removal by the sawing technique
Foreign body granuloma and synovitis of the finger: A hazard of ring removal by the sawing technique A case of chronic digital synovitis and foreign body reaction secondary to metallic filings js reported. The patient had a digital mass and a previous history of a ring finger injury. A saw action ring remover was implicated as a source of foreign bodies produced by ring removal over the open wound. Care should be taken to avoid implantation of metal filings with this technique, and an alternate method of removing rings from injured fingers should be considered. (J HAND SuRG 1987;12A:621-3.)
Frank J. Fasano, Jr., M.D. and Reid H. Hansen, M.D., Springfield, Ill.
Soft tissue injury of the ring fingeris com monly caused by avulsive forces applied to rings. Ad equate evaluation and treatment of such ring avulsion injuries necessitates removal of the circular band, which can become constricting if swelling occurs. 1 A common technique for ring removal employs the use of a small, hand operated circular saw. 2 We recently treated a patient with a complication, which may be attributed to the use of such a device.
Case report A 32-year-old, right-handed carpenter was seen in the hand clinic with a subcutaneous mass in the right ring finger. The mass was approximately 1 em in size, was slightly tender, and was located on the palmar surface of the finger. It had been slowly growing over the past 2 years. Ten years pre viously the patient had lacerated the proximal portion of the finger and had to have his high school class ring removed from the finger in the area of the open wound. A sawing device had been used to remove the ring. The patient declined surgical treatment and was followed up for an additional 2 years, during which time the mass
From the Southern Illinois University School of Medicine, Depart ment of Surgery, Division of Orthopaedics and Rehabilitation, and Division of Plastic Surge!)', Springfield, Ill. Received for publication Sept. 29, 1986; accepted in revised form Nov. 24, 1986. No benefits in any form have been received or will be received from a commercial party related directly or indirectly to the subject of this article. Reprint requests: Frank J. Fasano, Jr., M.D., SIU School of Medi cine, Department of Surgery, Division of Orthopaedics and Re habilitation, P.O. Box 3926, Springfield, IL 62708.
Fig. 1. The ring finger showing the soft tissue mass at the proximal phalangeal level. slowly grew in size (Fig. 1). An x-ray film showed mul tiple tiny opaque densities in the soft tissue mass (Fig. 2). Use of the hand at work began to cause increasing tenderness leading the patient to agree to surgical ex cision. THE JOURNAL OF HAND SURGERY
621
622
Fasano and Hansen
Fig. 2. X-ray film of the digit showing multiple opaque den sities in the soft tissue.
The Journal of HAND SURGERY
Fig. 3. Intraoperative photograph of the soft tissue mass.
Fig. 4. Multiple noncaseating granulomas, with tiny foreign bodies in the center. There is evidence of lymphocytic infiltration suggesting a chronic inflammatory reaction. (Original magnification x40.)
Vol. 12A, No. 4 July 1987
At the time of operation, a firm mass measuring 3 X 2.5 X 1.5 em was found to be encasing the digital neuro vascular bundles (Fig. 3) and involving the flexor synovial tissue. Pathologic examination showed the mass to be composed of thickened synovium and many noncaseating granulomas. Multiple minute foreign bodies were seen in the center of the granulomas. Infiltrations of lymphocytes and plasma cells were noted. The appearance was highly suggestive of a for eign body reaction (Fig. 4). Postoperatively the patient regained normal use of the fin ger, and there has been no recurrence of the mass during 1 year of follow-up.
Discussion
Foreign body reaction of the digits 3-5 has been re ported in patients in a number of occupations. Chronic synovitis is also known to occur after silicone arthro plasty secondary to degeneration and microscopic frag 1mentation of the implant. Removal of foreign material is essential in the treat ment· of any wound to minimize the risk of infection and the formation of reactive scar tissue. Metal frag ments are well tolerated, and local reaction may be minimal. The history of previous soft tissue injury and ring removal, together with the radiologic and pathologic findings, indicate that metal filings produced by a ring saw probably produced a chronic low-grade foreign
Foreign body granuloma and synovitis offinger
623
body inflammatory reaction. The mass became apparent 8 years after the initial injury and grew over the fol lowing 4 years before excision. If ring removal is necessary in the area of an open wound, removal by a saw should be done with care not to implant the metal filings. Such precautions are no tably absent in the instructions that accompany one such sawing device. 2 A well established altemative tech nique6· 7 is the use of~ suture, which is wrapped around the swollen finger distal to and under the ring. Such a technique allows removal of the ring without its de struction and avoids contamination of the finger by metal fragments. REFERENCES 1. Carroll RE. Ring injuries in the hand. Clin Orthop
1974;104:175-82. 2. Beaver emergency finger ring cutter. Waltham, Mass: In structional brochure, 1986. 3. Balasubramaniam P, Prathap K. Pseudotumors due to oil palm thorn injury. Aust NZ J Surg 1977;47:223-5. 4. Merrell JC, Petro JA, Miller SH. Osseous foreign body reaction in the hand. Ann Plast Surg 1980;4:154-7. 5. White AG. Gold spinner's hand. Br J Clin Practice 1971;25:147-8. 6. Henry ML. Simplified ring removal. Surgical Rounds 1986;96. 7. Mizrahi S, Lunski I. A simplified method for ring removal from an edematous finger. Am J Surg 1986;151:412-3.
Frank J. Fasano, Jr., M.D. and Reid H. Hansen, M.D., Springfield, Ill.
Soft tissue injury of the ring fingeris com monly caused by avulsive forces applied to rings. Ad equate evaluation and treatment of such ring avulsion injuries necessitates removal of the circular band, which can become constricting if swelling occurs. 1 A common technique for ring removal employs the use of a small, hand operated circular saw. 2 We recently treated a patient with a complication, which may be attributed to the use of such a device.
Case report A 32-year-old, right-handed carpenter was seen in the hand clinic with a subcutaneous mass in the right ring finger. The mass was approximately 1 em in size, was slightly tender, and was located on the palmar surface of the finger. It had been slowly growing over the past 2 years. Ten years pre viously the patient had lacerated the proximal portion of the finger and had to have his high school class ring removed from the finger in the area of the open wound. A sawing device had been used to remove the ring. The patient declined surgical treatment and was followed up for an additional 2 years, during which time the mass
From the Southern Illinois University School of Medicine, Depart ment of Surgery, Division of Orthopaedics and Rehabilitation, and Division of Plastic Surge!)', Springfield, Ill. Received for publication Sept. 29, 1986; accepted in revised form Nov. 24, 1986. No benefits in any form have been received or will be received from a commercial party related directly or indirectly to the subject of this article. Reprint requests: Frank J. Fasano, Jr., M.D., SIU School of Medi cine, Department of Surgery, Division of Orthopaedics and Re habilitation, P.O. Box 3926, Springfield, IL 62708.
Fig. 1. The ring finger showing the soft tissue mass at the proximal phalangeal level. slowly grew in size (Fig. 1). An x-ray film showed mul tiple tiny opaque densities in the soft tissue mass (Fig. 2). Use of the hand at work began to cause increasing tenderness leading the patient to agree to surgical ex cision. THE JOURNAL OF HAND SURGERY
621
622
Fasano and Hansen
Fig. 2. X-ray film of the digit showing multiple opaque den sities in the soft tissue.
The Journal of HAND SURGERY
Fig. 3. Intraoperative photograph of the soft tissue mass.
Fig. 4. Multiple noncaseating granulomas, with tiny foreign bodies in the center. There is evidence of lymphocytic infiltration suggesting a chronic inflammatory reaction. (Original magnification x40.)
Vol. 12A, No. 4 July 1987
At the time of operation, a firm mass measuring 3 X 2.5 X 1.5 em was found to be encasing the digital neuro vascular bundles (Fig. 3) and involving the flexor synovial tissue. Pathologic examination showed the mass to be composed of thickened synovium and many noncaseating granulomas. Multiple minute foreign bodies were seen in the center of the granulomas. Infiltrations of lymphocytes and plasma cells were noted. The appearance was highly suggestive of a for eign body reaction (Fig. 4). Postoperatively the patient regained normal use of the fin ger, and there has been no recurrence of the mass during 1 year of follow-up.
Discussion
Foreign body reaction of the digits 3-5 has been re ported in patients in a number of occupations. Chronic synovitis is also known to occur after silicone arthro plasty secondary to degeneration and microscopic frag 1mentation of the implant. Removal of foreign material is essential in the treat ment· of any wound to minimize the risk of infection and the formation of reactive scar tissue. Metal frag ments are well tolerated, and local reaction may be minimal. The history of previous soft tissue injury and ring removal, together with the radiologic and pathologic findings, indicate that metal filings produced by a ring saw probably produced a chronic low-grade foreign
Foreign body granuloma and synovitis offinger
623
body inflammatory reaction. The mass became apparent 8 years after the initial injury and grew over the fol lowing 4 years before excision. If ring removal is necessary in the area of an open wound, removal by a saw should be done with care not to implant the metal filings. Such precautions are no tably absent in the instructions that accompany one such sawing device. 2 A well established altemative tech nique6· 7 is the use of~ suture, which is wrapped around the swollen finger distal to and under the ring. Such a technique allows removal of the ring without its de struction and avoids contamination of the finger by metal fragments. REFERENCES 1. Carroll RE. Ring injuries in the hand. Clin Orthop
1974;104:175-82. 2. Beaver emergency finger ring cutter. Waltham, Mass: In structional brochure, 1986. 3. Balasubramaniam P, Prathap K. Pseudotumors due to oil palm thorn injury. Aust NZ J Surg 1977;47:223-5. 4. Merrell JC, Petro JA, Miller SH. Osseous foreign body reaction in the hand. Ann Plast Surg 1980;4:154-7. 5. White AG. Gold spinner's hand. Br J Clin Practice 1971;25:147-8. 6. Henry ML. Simplified ring removal. Surgical Rounds 1986;96. 7. Mizrahi S, Lunski I. A simplified method for ring removal from an edematous finger. Am J Surg 1986;151:412-3.