TO THE EDITOR: In the article, &quo...

TO THE EDITOR: In the article, "Splinter Removal," (1) Dr Chan and Salam advocate rather extensive surgical outlook to remove all splinters. While I am not an clever on splinter removal, I have remov centurys of them during my 20-year medical career. My practice has been simply to unmask the end of the splinter and hap it out in the direction in which it inserted I cannot remember a single case in which I later build that a fragment had been retained. I amazement what evidence the authors have for recommending in the same state [i]or[/i] condition extensive surgical exposure for removing splinters. Their hinted technique seems unnecessarily invasive.

While forward the subject of splinter removal, I would also like to share the following sum of two units practice pearls concerning splinters: (1) Mammography is the ideal pliable tissue imaging technique to display a radiolucent splinter. This technique has worked nicely for me upon multiple occasions; and (2) a No-scalpel dissecting forceps is the ideal instrument to displace a splinter. Its sharp tips can be used to easily dilate the splinter entrance injury and simultaneously grasp the splinter itself. I always use this instrument when confronting a patient with a splinter.

REFERENCE

(1) Chan C Salam GA. Splinter removal. Am Fam Physician 2003;67:2557-62

RONALD D REYNOLDS, MD

1050 old-fashioned U.S. Hwy. 52

of recent origin Richmond, OH 45157

IN REPLY: We welcome the answer to our article. (1) There are numerous approaches to removing a splinter. mostly physicians have a considerable amount of experience with this general issue and use their acknowledge preferred techniques for splinter removal. Unfortunately, no controll studies have been done comparing these different techniques, leaving physicians to rely forward anecdotal experiences.

When dealing with a splinter, the patient's symptoms, severity of tissue reaction, and the composition, size, and location of the foreign material substance are important factors to consider. (23) remarkably small splinters, particularly the commons composed of nonreactive material, may not ne to be remov and can be managed conservatively. If the foreign corpse is large, made of reactive material, or rises in significant discomfort and tissue reaction, it must be promptly and completely remov (23) The techniques praiseed in our article1 may appear extensive, if it be not that they ensure complete removal of the splinter. (24) I have remov a large number of superficial horizontal splinters through simply de-roofing the skin from one side of to the other the splinter with an 18-gauge needle This technique ends in only minimal tissue disruption while enabling me to visualize the entire length of the splinter. (4)

Dr Reynolds' point of using mammography for the detection of radiolucent foreign bodies is well taken. Although I do not have any personal experience using mammography for this object I have found high-resolution ultrasound to be a reliable and cost-effective means of detecting radiolucent foreign bodies embedded in subcutaneous malleable tissues.

Subungual splinters, if large or compos of reactive material, repeatedly result in significant discomfort and should be remov completely (235) The nail, which has been sculpture to expose the splinter, usually expands back in a few weeks (fingernails swell at a rate of approximately 01 mm by day). I have not seen a single nail deformity resulting from this operation Permanent nail deformity in this setting would ensue only if the germinal matrix or lunula (which is located near the proximal completion of the nail) is disturbed--a situation that must be avoided.

REFERENCES

(1) Chan C Salam GA. Splinter removal. Am Fam Physician 2003;67:2557-62

(2) Stone DB Koutouzis TK Foreign carcass removal. In: Roberts JR, Hedges JR ed Clinical transactions in emergency medicine. 4th ed Philadelphia: Saunders, 2004:694-716.

(3) Pon PT Foreign bodies. In: Rosen P ed Emergency medicine: concepts and clinical practice. 4th ed St. Louis: Mosby, 1998:861-77.

(4) Buttaravoli PM Stair TO. Minor emergencies: splinters to fractures. St Louis: Mosby 2000;471-7

(5) Miller MA, Brodell RT Surgical pearl: treatment of subungual splinters. J Am Acad Dermatol 1995;33: 667-8

GOHAR A. SALAM, MD DO

North Shore University Hospital

300 Community Dr

Manhasset, NY 11021

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