A Rare Case of Fish Bone Penetrating Injury to Radius Causing Osteitis and Non-Healing Sinus

doi:10.4236/ojo.2013.35041

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Open Journal of Orthopedics, 2013, 3, 220-223

http://dx.doi.org/10.4236/ojo.2013.35041 Published Online September 2013 (http://www.scirp.org/journal/ojo)

A Rare Case of Fish Bone Penetrating Injury to Radius

Causing Osteitis and Non-Healing Sinus*

Paragjyoti Gogoi1#, Krishanu Kakati1, Sunil Poonia1, Aditi Das2

1Department of Orthopaedics & Trauma, Silc har Medical College, Silchar, India; 2Department of Radio-Diagnosis, Silchar Medical

College, Silchar, India.

Email: #[email protected]

Received July 25th, 2013; revised August 21st, 2013; accepted August 28th, 2013

which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

ABSTRACT

Penetrating injury to radius or any other bone by fish bone is a rare kind of injury. Commonly metallic sharp objects,

bullets, sharpnels, glass particles, hard wooden pieces are the causes of penetrating injury to bones. Radio-opaque ob-

jects are easy to detect and thus retrieval is relatively simpler than the radiolucent objects. Non-biological foreign bod-

ies do not incite any reaction in the host bone whereas biological foreign bodies of either plant or animal origin cause

hypersensitivity reaction. Osteitis along with excessive formation of new bones may be presented as a part of host reac-

tion to the foreign body. We are presenting here an interesting case of a fisherman boy who sustained penetrating injury

to radius by fish bone resulting in osteitis and a chronic non-healing sinus with watery discharge.

Keywords: Fish Bone; Foreign Body; Granuloma; Penetrating Injury; Radio-Opaque

1. Introduction

Foreign body retained in the soft tissues of extremities

causing sinus formation is not uncommon. Mostly the

working class people are affected. Wooden foreign body,

blackthorn injury, glass particle, metallic pieces are the

major causes of granuloma formation along with sinus

[1-3]. A case of fisherman penetrating injury by fish

bone along with granuloma formation is reported [4].

However, fish bone penetrating the bone causing osteitis

and granuloma formation is very rare. We are reporting a

very unusual case of fish bone injury to forearm where

the fish bone penetrated the radius and there were osteitis

and granuloma formations along with a sinus. Perhaps

this is the first case of this kind. The purpose of this

paper is to highlight the uniqueness and the rarity of this

case and to bring to the fore the necessary discussion in

management of medical and surgical oddities.

2. Case Report

A 14-year-old boy attended our outpatient department

with pain over left forearm and a discharging sinus on

the volar aspect. He gave a peculiar history of sustaining

trauma over his left forearm. He hailed from a fisherman

family and while helping his father out in transferring big

fishes from one container to another he fell down over a

big fish and sustained injury over his left forearm. There

was a pricking injury which healed after primary treat-

ment and some medications. He was normal for four

months except some catch in some rotational movement.

Gradually he started having pain over the forearm along

with slight swelling. With in two weeks of pain, he devel-

oped a sinus over the volar aspect of left forearm near the

old pricking site with some watery discharge.

On examination a scarred area was noted over the

volar aspect of mid-forearm with a small sinus with wa-

tery discharge (Figure 1). The sinus seemed to be ad-

hered to underlying soft tissues and mild tenderness on

palpation was noted. Range of movement of elbow and

wrist were within normal limits. There was mild pain at

the extremes of pronation and supination of the forearm.

X-rays of the forearm revealed a radio-opaque linear

foreign body impinging the radius and surrounded by

new bone formation and a lytic radio-lucent ream (Fig-

ures 2 and 3). Marked osteitis with extensive periosteal

reaction is noted both proximal and distal to the foreign

body. Musculo-skeletal ultrasonography using high fre-

quency probe confirmed the foreign body along with

formation of a granulomatous mass surrounding it (Fig-

*Conflict of Interests: The authors declare that they have no conflict o

interests. Consent: Informed consent was taken f o r this work.

#Corresponding author.

A Rare Case of Fish Bone Penetrating Injury to Radius Causing O s te i t i s a nd Non-Healing Sinus 221

Figure 1. Sinus formation in forearm.

Figure 2. AP view showing fish bone and osteitis of radius

with new bone formation.

Figure 3. Lateral view show ing r adio-luce ny around the fis h

bone and periosteal reaction of radius.

ures 4 and 5). There was no injury to the neuro-vascular

structures.

Blood parameters revealed leucocytosis with eosino-

philia and ESR was mildly elevated. Chest X-ray was

normal.

From the clinical history and radiological pictures the

diagnosis of retained foreign body impinging the radius

with osteitis was made and decision taken to explore the

lesion.

The lesion was addressed by anterior Henry’s ap-

proach. The sinus was excised. The area was exposed

well with due care and the fish bone iden tified impinging

the radius. There was necrotic area around the fish bone

covered by a fibrotic pseudo-capsule. The fish bone re-

moved in single piece and measured 28 mm with a sharp

pointing end (Figures 6 and 7). The fibous pseudocap-

sule surrounding the fish bone was excised (Figure 8).

Extensive new bone formation was noted in the radius

around the impinged area. There was a central crater

filled with necrotic material surrounded by new bones

(Figure 9). The new bones were chiseled out to get a

smooth contour of the radius (Figure 10). Thorough cu-

rettage of the area was done and the material sent for

histology. Histological picture of the curetted material

was consistent with those of a granuloma.

Figure 4. Ultrasonography of forearm.

Figure 5. USG showing embedded for eign body.

Figure 6. Fish bone removed in toto.

A Rare Case of Fish Bone Penetrating Injury to Radius Causing Osteitis and Non-Healing Sinus

222

Figure 7. Fish bone measuring 28 mm.

Figure 8. Excised fibrous pseud o c a psule .

Figure 9. Crater on the ra dius surr ounded by new bone s.

Figure 10. Excessive new bone chiseled out.

Post-operative X-rays confirmed thorough removal of

the foreign body an d removal of new bones (Figure 11).

The surgical wound healed well and the boy got rid of

the symptoms. He was followed up for six months and no

Figure 11. Post operative X-ray.

recurrence of sinus was there.

3. Discussion

Fishing is regarded as one of the oldest professions.

Many people derive their livelihood from fishing. It is

also seen as a great recreational activity. But this is also

not free from injury risks like many other professions.

Mostly injury occurs due to penetrating injury by the fins

to the extremities [4,5]. In some rare instances penetra-

ting injury to heart can occur by long stings of some

species [6]. Some fishes contain venom in their stings

and fish envenomatosis require special care and treat-

ment. Apart from broad spectrum antibiotics, tetanus

toxoid, analgesics, this condition may demand specific

antivenom administration [7].

There have been many case reports on fish bone inju-

ries to hands and forearm as is evident in the study car-

ried out by Imberg R. et al. [4] in which 116 patients

were followed up with injuries sustained by fish bone to

their hands and forearm. Strangely enough not a single

case reported embedding of the fish bone to bone. To the

best of our knowledge the above mentioned study is the

most extensive one carried out in this matter.

Diagnosis of retained fish bone is not difficult. There

is always a history of penetrating injury resulting a skin

wound. Irrespective of the history it should be presumed

that there is a part of fish bone inside the body until all

investigations are over. X-ray usually detects the radio-

opaque fish bones. In case of radio-lucent objects ultraso-

nography is helpful [1,8]. Normally CT scan or MRI scan

is not required.

Inoculation of polymicrobial flora following fish bone

injury is a concern. There are reports of wound contami-

nation by unusual species like vibrio, actino-mycosis etc.

[9,10]. Broad spectrum antibiotics should always be re-

commended for such injury. Tetanus toxoid also may

have a role in preventing life threaten ing toxaemia.

Retained foreign bodies in the soft tissues incite granu-

lomatous reaction. The host tries to isolate the biological

A Rare Case of Fish Bone Penetrating Injury to Radius Causing O s te i t i s a nd Non-Healing Sinus

223

foreign body by forming a granuloma around it [8]. In

the centre of the granuloma there lies the foreign body

and a layer of necrotic tissues surrounding it.

Penetration of the host bone by fish bone is a rare

event. There is a host reaction in the form of osteitis or

periosteal reaction. There is formation of excessive bone

surrounding the fish bone which is akin to granuloma

formation in soft tissues. In this particular case the fish

bone was long enough to have partly inside the radius

and partly in soft tissues of fo rearm. Th erefore w e found

excessive fibrous tissu es surrounding the fish bone in th e

soft tissue part and excessive bone formation around it in

the bony tract. The rareness of this case and the relative

dearth of literature in this matter compelled us to direct

our treatment towards normal protocol of granulamatous

infections of bone. The persistence of infection for four

months and the osteitis led us to take the decision of

surgical exploration immediately and excision of the

sinus tract along with curettage of the bon e.

4. Conclusion

In penetrating injury by fish, the possibility of the

retained part inside the body should always be su spected.

The presence of sinus reconfirms this suspicion. X-ray is

the most commonly used noninvasive investigations to

detect radio-opaque foreign bodies. Ultrasonography de-

tects the presence of radiolucent objects and highlights

the soft tissue conditions like granuloma formation, pre-

sence of abscess and exact location. Surgical removal as

well as excision of the granulomatous sinus tract is the

rule. Broad spectrum antibiotics help in rapid healing and

can also cover the unusual pathogens.

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