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Ultrasound compared with projection radiography for the detection of soft

tissue foreign bodies - A technical note

Article · September 2023

DOI: 10.1016/j.radi.2023.08.005

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 Radiography 29 (2023) 1007e1010

Contents lists available at ScienceDirect

Radiography
journal homepage: www.elsevier.com/locate/radi

Technical note

Ultrasound compared with projection radiography for the detection of

soft tissue foreign bodies e A technical note
H. Grocutt a, R. Davies b, C. Heales b, *
a
Royal Cornwall Hospitals NHS Trust, Treliske, Truro, TR1 3LJ, United Kingdom
b
University of Exeter, St Luke's Campus, Heavitree Road, Exeter, EX1 2LU, United Kingdom

a r t i c l e i n f o a b s t r a c t

Article history: Introduction: Soft tissue foreign bodies (STFBs) present a diagnostic challenge depending on their
Received 15 June 2023 composition. Untreated complications can arise, namely infection through to loss of function. General
Received in revised form (projection) radiography is recommended as the first line imaging examination. However, some STFBs
21 August 2023
are radiolucent, leading to false negative radiographs. The aim of this in vitro study was to compare
Accepted 22 August 2023
Available online 2 September 2023
ultrasound with projection radiographs for the detection of a range of different types of STFB.
Method: Ethical approval (for use of participants to evaluate images) was granted by the Higher Edu-
cation Institute's departmental Ethics Committee. Seven hand phantoms were created from a water,
Keywords:
Foreign bodies
gelatine and psyllium mix. A different STFB (radiolucent and radiopaque) was inserted into six phantoms,
Projection radiography with the seventh being a control. Ultrasound and projection radiograph images were generated of each
Soft tissue foreign bodies phantom. Participants (academics and radiography students) reviewed all images.
Ultrasound Results: 50 responses were received from a study population of approximately 400, (10 academics, 40
students). The ability of ultrasound to detect radiolucent foreign bodies performs well compared with
projection radiography: sensitivity 94% versus 9%, specificity 90% versus 88%. For radiopaque foreign
bodies the data was more mixed: sensitivity 96% versus 99%, specificity 90% versus 88%.
Discussion: These data suggest that ultrasound is superior to projection radiography for the detection of
radiolucent STFBs. Limitations include the lack of formal postgraduate ultrasound training within the
study population and a lack of simulated bony structure within the hand phantoms.
Implications for practice: Ultrasound has the potential to be a useful modality in the detection of STFBs,
particularly radiolucent objects. There are associated challenges such as conducting ultrasound in the
vicinity of a wound, but further exploration of this application of ultrasound is warranted.
© 2023 The Author(s). Published by Elsevier Ltd on behalf of The College of Radiographers. This is an
open access article under the CC BY license (http://creativecommons.org/licenses/by/4.0/).

Introduction recommends general radiography as the primary modality of

choice.8e10 However, some STFBs are radiolucent3,11 resulting in
Lacerations and puncture wounds represent a significant false-negative radiographs. This leads to late diagnosis, increased
number of Emergency Department (ED) attendances in the United health complications and potential litigation costs to the National
Kingdom (UK).1 Such injuries frequently result in soft tissue Health Service (NHS).12,13
foreign bodies (STFBs) due to the deposition of wooden splinters, Research has indicated that ultrasonography could be a viable
gravel and shards of glass.2 Left untreated these can cause infec- non-ionising radiation alternative for STFB detection.14e16 It's
tion and/or lead to complications such as loss of function and even ability to diagnose STFBs of differing materials and densities (both
cancer.3e7 Guidance from the Royal College of Radiologists (RCR) radiopaque and radiolucent), has been suggested in numerous
and the National Institute for Health and Care Excellence (NICE) studies over a significant period of time17e21 albeit studies of a
heterogeneous nature.3 The aim of this study was to investigate
the role of ultrasound in the detection of STFBs through a
controlled phantom study using a mixed method survey of aca-
demic staff and diagnostic radiography learners at the Higher
* Corresponding author. Education Institute (HEI) where the author was enrolled on a pre-
E-mail addresses: hannah.grocutt@nhs.net (H. Grocutt), r.c.davies@exeter.ac.uk
(R. Davies), c.j.heales@exeter.ac.uk (C. Heales).
registration programme of study.

https://doi.org/10.1016/j.radi.2023.08.005
1078-8174/© 2023 The Author(s). Published by Elsevier Ltd on behalf of The College of Radiographers. This is an open access article under the CC BY license (http://
creativecommons.org/licenses/by/4.0/).
H. Grocutt, R. Davies and C. Heales Radiography 29 (2023) 1007e1010

Methods

Ethical approval for the use of participants to evaluate the im-

ages (academic staff and learners) was granted by the Higher Ed-
ucation Institute's departmental Ethics Committee under the
process for approval of undergraduate research projects.

Phantom methods

Seven hand phantoms were created using a mixture of water,

gelatine and psyllium (determined to be a suitable soft tissue
mimic) inside rubber gloves.16,22 Foreign bodies of varying mate-
rials, sizes and densities, representative of the range of STFBs found
in practice were inserted into six of the seven gloves (in the central
palmar area) by a colleague, so that the primary researcher un-
dertaking the imaging would be blinded to the contents of each
phantom. An equal quantity of radiopaque and radiolucent foreign
bodies were selected. Table 1 provides further information on each
phantom.

Imaging methods

Each phantom was imaged by a final year pre-registration

learner (following appropriate education and training in the rele-
vant modalities) under the guidance of appropriately qualified and
experienced academic radiographers. For projection radiography a
Siemens Multix Fusion tube and x-ray table were used together
with an Agfa XDþ14 image receptor. Dorso-posterior (DP) and
lateral projections were performed using fine focus, a 100 cm
source to image receptor distance, 55 kVp and 1.5 mAs. Fig. 1 shows
a DP projection of a phantom containing a glass foreign body. As it
was intended to evaluate the relative ability of ultrasound
compared with projection radiography in detecting the presence of
STFBs, site entry (wound) markers were not utilised for the pro-
jection radiographs.
For ultrasound imaging, a Siemens Acuson X700 with a
10.7 MHz linear probe was combined with the musculoskeletal pre-
Figure 1. Projection Radiograph (dorso-palmar) of phantom with glass foreign body.
settings and the phantoms were imaged at a frame rate of 32
frames per second. Depth was adjusted manually. Images were
downloaded from each imaging system, with the ultrasound cine presented sequentially. The Microsoft Form was set up such that
images being converted to MP4 files. Fig. 2 shows a still image from responses were anonymous; hence participants were advised that
the ultrasound cine showing the phantom with the thorn foreign their responses could not be identified for removal from the study
body in situ. should they wish to withdraw after they had submitted their
responses.
Survey methods

Microsoft Forms was selected as the digital survey platform as it

was available to the intended recipients via their university logins
and supported the uploading of images and video. Participant in-
formation and consent, and reference to ethical approval, was
included on the first page of the survey. The images themselves
were then arranged in a random order i.e., the projection radio-
graph and ultrasound of the same phantom were not always

Table 1
Phantom composition.

Phantom number Material Property Size (cm)

1 Glass Radiolucent 1.7 x 0.8 x 0.3

2 Thorn Radiolucent 1.1 x 1 x 0.1
3 (control) None Not applicable Not applicable
4 Plastic Radiolucent 2.2 x 0.3 x 0.1
5 Gravel Radiopaque 0.7 x 0.5 x 0.4
6 Stainless Steel Radiopaque 3 x 0.1 x 0.1
7 Wood Radiolucent 2.5 x 0.2 x 0.2 Figure 2. Ultrasound image of phantom with thorn foreign body.

1008
H. Grocutt, R. Davies and C. Heales Radiography 29 (2023) 1007e1010

The survey was constructed such that it contained a brief guide Table 2
on the detection of foreign bodies with both projection radiography The sensitivity and specificity of general radiography and ultrasound in STFB
detection.
and ultrasound. Respondents were asked to indicate whether they
were qualified or learner radiographers, and to indicate how much Modality Foreign Body Type Sensitivity Specificity
experience of ultrasound they have had. They were then asked to Projection radiograph All 53% 88%
assess the images and videos and determine whether a FB was Ultrasound All 95% 90%
present. Following an initial pilot study (3 academics and 3 Projection radiograph Radiolucent 9% 88%
Ultrasound Radiolucent 94% 90%
learners) which led to the refinement of some wording, the survey
Projection radiograph Radiopaque 99% 88%
was circulated within the Medical Imaging community within the Ultrasound Radiopaque 96% 90%
University via various electronic means (including discussion fo-
rums and information boards).
complications from undetected FBs.3,23 Projection radiography has
Results 99% sensitivity for radioopaque FBs so is slightly superior to the
findings for ultrasound from this study (96%) and a study by Car-
A total of 50 responses were received from the survey from a neiro et al.11 However, in many cases the composition of the FB is
population of approximately 400, equalling a response rate of 12%. unknown at presentation and 38% of STFBs may be missed due to
Of these responses, 10 were academics and 40 were pre- their radiolucency.16 A further advantage for the use of ultrasound
registration learners. 24 participants (48%) reported having less may be its ability to localise adjacent vessels and tendons3 thereby
than one month experience of ultrasound. facilitating safe ultrasound guided extraction.
Fig. 3 shows the comparative detection rates of each type of Despite nearly half of participants (48%) having limited experi-
foreign body. The difference in mean score between academics and ence observing and/or practicing ultrasound, the ability to detect
students was less than 1%, therefore, both academic and student STFBs in ultrasound was high in this study. A brief guide was pro-
results are displayed together. It can be observed that ultrasound vided as part of the survey which may have assisted with partici-
performs better for the radiolucent foreign bodies i.e., thorn, plastic pants’ ability to detect STFBs24 and a study completed by Nienaber
and wood. Using a paired t-test, these differences were found to be et al.25 has demonstrated that physicians were able to effectively
statistically significant with p < 0.01 in all three cases. It is of note scan and detect STFBs after an interactive session of only 20 min,
that 12% of respondents thought they had identified a foreign body with a sensitivity of 96.7%. Nevertheless, it could also be argued
in the control phantom on the radiographic images, and 10% on the that the relative ease of visualisation is indicative of the effective-
ultrasound images. ness of ultrasound as an imaging modality in relation to the
The sensitivity and specificity for both modalities were also detection of STFBs and its efficacy could be anticipated to be higher
calculated as shown in Table 2. in a cohort of experienced practitioners.

Discussion
Limitations
This study has demonstrated that ultrasound is effective for
detection of certain STFBs that are not as well detected by projec- It should be noted that the phantoms only replicated soft-tissue
tion radiography, namely those made of organic matter (wood and and were composed of a homogeneous material. Hence this study's
thorn) and plastic. Wood is the most common STFB so better findings may not be applicable to more bony parts of the body (such
detection using ultrasound has the potential to reduce as fingers). There would therefore be benefit in repeating this study

Foreign Body Detec on

100 100 100 100 100
98
100 94
96
Respondents identfying a Foreign Body / %

90
82

80

70

60

50
Projec on Radiography
40 Ultrasound
30
20
20
12
10
10 6
2

0
Glass Thorn Control Plas c Stone Metal Wood
Foreign Body Material

Figure 3. Accuracy of foreign body detection by study participants.

1009
H. Grocutt, R. Davies and C. Heales Radiography 29 (2023) 1007e1010

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