البروفيسور فريح ابوحسان – استشاري جراحة العظام في الاردن

1. Foot and Ankle Surgery 14 (2008) 32–35
Case report
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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.)*
Department of Orthopedics Surgery, Jordan University Hospital, Amman, Jordan
Received 5 March 2007; received in revised form 10 July 2007; accepted 11 July 2007
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 4 cm 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.
# 2007 European Foot and Ankle Society. Published by Elsevier Ltd. All rights reserved.
Keywords: Foot; Foreign body; Toothpick; Osteolysis
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 [3–7]. 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.
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).
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
* Correspondence address: P.O. Box 73, Jubaiha 11941, Jordan.
Tel.: +962 6 52 40 346; fax: +962 6 52 40 346.
E-mail address: freih@ju.edu.jo.
1268-7731/$ – see front matter # 2007 European Foot and Ankle Society. Published by Elsevier Ltd. All rights reserved.
doi:10.1016/j.fas.2007.07.002

2. F.O.A. Hassan / Foot and Ankle Surgery 14 (2008) 32–35 33
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.
proximally and distally on the dorsum of metatarsal bone
(Fig. 2A and B).
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 4 cm-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 inflam-mation
with foreign body giant cell reaction. Follow up
for 3 years showed remodeling of the metatarsal bone
(Fig. 4).
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 [4,8–13]. The time range fromthe
injury to the detection of the osseous lesionwas 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

3. 34 F.O.A. Hassan / Foot and Ankle Surgery 14 (2008) 32–35
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.
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 [9,14–16].
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,
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.
Fig. 3. Photograph of the removed toothpick.
Fig. 4. Plain radiograph after 3 years of surgery showing remodeling of the
first metatarsal.

4. F.O.A. Hassan / Foot and Ankle Surgery 14 (2008) 32–35 35
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.
References
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Table 1
Retained foreign bodies causing metatarsal osteolytic lesions
Author Type Duration of
injury (month)
Radiographic
findings
Floman and Katz [11] Wood 2 Osteolysis
Middha and
Vaishya [10]
Wood 1 Osteolysis,
periostitis
Siegel [9] Toothpick 4 Osteomylitis
Swischuk et al. [12] Wood 36 Periostitis
Weston [13] Thorn 6 Osteolysis
Dastgir and
O’Rourke [8]
Thorn 2 Osteolysis
Durr et al. [4] Thorn 4 Osteolysis
Our case Toothpick 24 Osteolysis