Foot and Ankle Surgery
Volume 14, Issue 1 , Pages 32-35, 2008

Retained toothpick causing pseudotumor of the first metatarsal: A case report and literature review

  • Freih Odeh Abu Hassan, F.R.C.S. (Eng.), F.R.C.S. (Tr. & Orth.)

      Affiliations

    • Corresponding Author InformationCorrespondence address: P.O. Box 73, Jubaiha 11941, Jordan. Tel.: +962 6 52 40 346; fax: +962 6 52 40 346.

Department of Orthopedics Surgery, Jordan University Hospital, Amman, Jordan

Received 5 March 2007; received in revised form 10 July 2007; accepted 11 July 2007.

Article Outline

Abstract 

We present a case of a retained toothpick causing pseudotumor of the first metatarsal in a young female who was referred as a case of painless swelling in the dorsolateral aspect of the right foot to exclude a malignant tumor.

Plain radiograph did show an osteolytic lesion in the head and neck of the first metatarsal. Magnetic resonance imaging revealed a toothpick inside the first metatarsal head. Surgical exploration revealed a 4cm toothpick embedded inside the bone surrounded by granulation tissue.

We could find seven cases of retained foreign bodies causing osteolytic lesions in the metatarsals of the foot with one case of osteomylitis in an adult due to a retained small piece of toothpick. Retained foreign body should be considered in the differential diagnosis of an osteolytic lesion of the foot.

Keywords: Foot, Foreign body, Toothpick, Osteolysis

 

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1. Introduction 

Penetrating wounds of the foot are common, but penetrating injuries to the bone are rare [1], [2]. Thorns, glass, needles or wood fragments are the main foreign bodies that are retained in the foot or hand, creating soft tissue and bony granuloma [3], [4], [5], [6], [7]. Symptoms may develop months to years after a forgotten injury [3], [4].

We report a case of toothpick-induced osteolytic pseudotumor of the first metatarsal and review the findings concerning seven other foreign bodies causing metatarsal osteolytic lesions reported in the literature.

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2. Case report 

A 13-year-old healthy female child was referred as a case of painless swelling in the dorsolateral aspect of the left foot to exclude a malignant tumor. She denied any history of trauma or injury initially but after we reached the diagnosis she recalled some thing pricked her 2 years back and she consulted the local health center, where she had plain radiograph to the foot. She was told that there was nothing inside her foot.

Physical examination showed a healthy patient with no evidence of any neuromuscular disorders. Locally a non-tender mass was found on the dorsolateral aspect of the left foot. The overlying skin was intact with no local signs of inflammation or skin break.

Laboratory investigations revealed normal white blood cell count, a normal C-reactive protein level and normal erythrocyte sedimentation rate. A plain radiograph of the left foot showed an oblique osteolytic lesion of the cortex and the medullary space in the head and neck of the first metatarsal (Fig. 1A and B).

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  • Fig. 1. 

    (A) Anterior–posterior view of plain radiograph of the left foot showing the osteolytic lesion. (B) Oblique view of plain radiograph of the left foot showing the osteolytic lesion.

Magnetic resonance imaging confirmed a destructive lesion in the centre of the first metatarsal head and neck with marked soft-tissue reaction dorsal to the metatarsal. The toothpick was seen as a hypo-intense structure in the center of the lesion, extending obliquely proximally and distally on the dorsum of metatarsal bone (Fig. 2A and B).

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  • Fig. 2. 

    (A) MRI of the left foot showing the toothpick surrounded by soft-tissue edema. (B) MRI of the foot showing the dorsal osteolyic lesion in the first metatarsal.

Surgical exploration through a dorsal approach to the first metatarsal head with retraction of the extensor hallucis tendons, revealed destruction in the dorsolateral aspect of the cortex of head and neck, replaced by granulation tissue. In the cavity, a 4cm-long toothpick was found and removed (Fig. 3).

The lesion was curetted and irrigated. No bone graft or bone substitute was inserted into the residual cavity. No bacteria grew on cultures of the foreign body and the granulation tissue. Biopsy showed mixed chronic inflammation with foreign body giant cell reaction. Follow up for 3 years showed remodeling of the metatarsal bone (Fig. 4).

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3. Discussion 

The hand is the most common location for foreign bodies, because it is easily exposed to injury [3], [5]. The foot is the second most common location for retained foreign bodies [3], [4]. Seven cases of thorn and wood induced osteolytic lesions of metatarsal bones have been reported in the English literature in the last 44 years [4], [8], [9], [10], [11], [12], [13]. The time range from the injury to the detection of the osseous lesion was 1–36 months.

Retained foreign bodies in the foot have been reported to cause a pathological reaction (osteolytic, osteoblastic or a combination), the radiological appearance of which may resemble osteomyelitis or bone tumor [3], [4].

Of the seven reported metatarsal lesions, five had osteolysis, one had periosteal reaction and one had a combination of both (Table 1). The single case report of a retained toothpick was due to a small piece of toothpick in an adult patient which caused Eikenella corrodens metatarsal osteomyelitis after 4 months of injury [9]. The remaining cases were due to retained thorn or piece of wood.

Table 1. Retained foreign bodies causing metatarsal osteolytic lesions
AuthorTypeDuration of injury (month)Radiographic findings
Floman and Katz [11]Wood2Osteolysis
Middha and Vaishya [10]Wood1Osteolysis, periostitis
Siegel [9]Toothpick4Osteomylitis
Swischuk et al. [12]Wood36Periostitis
Weston [13]Thorn6Osteolysis
Dastgir and O’Rourke [8]Thorn2Osteolysis
Durr et al. [4]Thorn4Osteolysis
Our caseToothpick24Osteolysis

Our case represents a retained whole toothpick in an adolescent patient with subsequent osteolysis, with no evidence of osteomyelitis in spite being retained for 2 years of injury. These osteolytic reactions form the commonest features of chronic foreign bodies reaction.

Ultrasonography, magnetic resonance imaging (MRI), and computed tomographic scanning (CT Scan) have been used to facilitate the detection of foreign bodies [9], [14], [15], [16]. In our case the MRI detected the osteolytic lesion, the surrounding granulation tissue and the toothpick embedded inside the osteolytic lesion.

MRI scan is considered a reliable tool in visualization of retained foreign bodies in the foot [4], [8], [15] and in this case, the toothpick was hypo-intense on T1-weighted images, and a thin rim of enhanced tissue was seen after intravenous injection of gadolinium (Fig. 2).

The most important factor in identification of the foreign body is a surrounding rim of fluid-rich granulation tissue or a fluid-filled cyst. On T2-weighted, however, the high signal intensity of the granulation tissue may outshine the foreign body and make identification difficult [4]. The characteristic clinical and radiographic patterns of foreign bodies should be remembered in the differential diagnosis of osteomylitis or foot tumours.

When the retained foreign body comes in contact with the bone it will cause irritation and induce an inflammatory reaction which will cause osteolysis of the bone, but after removal of the foreign body and curettage of the lesion, remodeling of the osteolytic lesion can occur as in our case. This indicates that it is not important to fill a defect of such size in the young and adolescent age group.

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References 

  1. Kelly JJ. Blackthorn inflammation. J Bone Joint Surg [Br]. 1966;48:474–477
  2. Maylahn DJ. Thorn-induced “tumors” of bone. J Bone Joint Surg [Am]. 1952;34:386–388
  3. Reginato AJ, Ferreiro JL, O’Connor CR, Barbasan C, Arasa J, Bednar J, et al. Clinical and pathologic studies of twenty-six patients with penetrating foreign body injury to the joints, bursae, and tendon sheaths. Arthritis Rheum. 1990;33:1753–1762
  4. Durr HD, Stabler A, Muller PE, Refior HJ. Thorn induced pseudotumor of the metatarsal. J Bone Joint Surg (A). 2001;83(4):580–584
  5. Borgia CA. An unusual bone reaction to an organic foreign body in the hand. Clin Orthop. 1963;30:188–193
  6. Barry M, Maffulli N, Good C. The missed thorn. Acta Orthop Belg. 1992;58:468–470
  7. Hughes SF, Maffulli N, Fixsen JA. Thorn-induced granuloma of the medial cuneiform. J Foot Surg. 1992;31:247–249
  8. Dastgir N, O’Rourke P. Pseudotumor of metatarsal: a thorny problem. Int J Orthopedic Surg. 2003;1(2):
  9. Siegel IM. Identification of non-metallic foreign bodies in soft tissue: Eikenella corrodens metatarsal osteomyelitis due to a retained toothpick. A case report. J Bone Joint Surg [Am]. 1992;74:1408–1410
  10. Middha VP, Vaishya R. Lesions produced by splinters of wood in soft tissues and bone. Int Orthop. 1990;14:47–48
  11. Floman Y, Katz S. Osseous lesion simulating a bone tumour due to an unsuspected fragment of wood in the foot. Injury. 1975;6:344–345
  12. Swischuk LE, Jorgenson F, Jorgenson A, Capen D. Wooden splinter induced “pseudotumors” and “osteomyelitis-like lesions” of bone and soft tissue. Am J Roentgenol Radium Ther Nucl Med. 1974;122:176–179
  13. Weston WJ. Thorn and twig-induced pseudotumors of bone and soft tissues. Br J Radiol. 1963;36:323–326
  14. Banerjee B, Das RK. Sonographic detection of foreign bodies of the extremities. Br J Radiol. 1991;64:107–112
  15. Kornreich L, Katz K, Horev G, Zeharia A, Mukamel M. Preoperative localization of a foreign body by magnetic resonance imaging. Eur J Radiol. 1998;26:309–311
  16. Mizel MS, Steinmetz ND, Trepman E. Detection of wooden foreign bodies in muscle tissues: experimental comparison of C.T, MRI and ultrasonography. Foot Ankle Int. 1994;15:437–443

PII: S1268-7731(07)00067-7

doi:10.1016/j.fas.2007.07.002

Foot and Ankle Surgery
Volume 14, Issue 1 , Pages 32-35, 2008

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