December 2008 no white pages.indd Orthopaedic Manifestations of Date Thorn Injury Case series S S Suresh SULTAN QABOOS UNIVERSITY MEDICAL JOURNAL NOVEMBER 2008, VOLUME 8, ISSUE 3, P. 347-352 SULTAN QABOOS UNIVERSITY© SUBMITTED - 30TH APRIL 2008 ACCEPTED - 18TH AUGUST 2008 C A S E R E P O R T النخيل بأشواك العظام إصابات مظاهر حاالت مجموعة اس سوريش اس عندالفالحني حتدث االصابات معظم فيها. النخيل زراعة حيث تكثر ــط األوس في أقطار الشرق االنتشار ــعة واس النخيل ــواك االصابات بأش امللخص: جتلب أال وميكن بها العلم دون حتدث ميكن أن األطفال عند هناك اختالطات، لكن االصابات يكون مبكرا ال االصابات وتعالج عندما تكتشف واألطفال. األكثر عرضة لالصابات. تكون ــا فانه ــم اجلس باقي من عرضة األكثر اجلزء أن اليد هي ومبا اختالطات متأخرة. حدوث ــبب في يتس مما اليها ــل األه ــاه انتب املزروعة املناطق في عارية تكون هي االخرى عندما تصاب ميكن أن القدم أن كما والنقي. العظم التهاب أن تعمل آفات تشبه ميكن املنطمرة االشواك من اليد اصابات في ــم لديه الذين الثالثة املرضى عانى ــرة. اختالطات متأخ حصول بعد النخيل ــواك بأش حاالت مصابة ــا خمس هن ــدرج ن ــل. بالنخي في العظام آفات انحالل اآلخرين املريضني كان لدى العظم والنقي. التهاب الى أدت العظم في ــوكة ش من ــكو يش أحدهم وكان ــمحاق، الس التهاب العظام. في اختالطات متاما دون شفيت كل احلاالت العظم. داخل شوكة احداهما لدى وكان املشطية، حالة. تقرير احلبيبي، الغريب اجلسم ورم السمحاق، التهاب والنقي، العظم التهاب العظم، كيس ، املشطية العظام اليد، الكلمات: مفتاح Departmentof Orthopaedics, Ibri Regional Hospital, Muscat, Sultanate of Oman Email: dr.s.s.suresh@gmail.com ORGANIC FOREIGN BODY GRANULOMA, including date thorn, should be considered in the differentials of a lytic lesion with or without sclerotic lesions of the bone.1, 2 The foreign body reaction which results from thorn injury can mimic various bone, joint and soft tissue disorders.1, 2, 3, 4, 5, 6, 7, 8, 9 Date palm thorn injuries are common in the Sultanate of Oman with its extensive farming of date palms. The thorns, lying beneath the trees in places where children play, produce injuries to exposed parts, mostly in the hands, knees and foot. There are various reports of date palm thorn injuries in the literature, with eight cases of metacarpal lesions reported so far.6 There are reports of thorn induced osteomyelitis of the metatarsals and cuboid,10 from areas where people walk barefoot. M E T H O D S Data regarding all patients who presented to Ibri Re- gional Hospital with the following ICD (International Classification of Diseases) codes were reviewed for the last 4 years: ABSTRACT Date palm thorn injuries are common in Middle Eastern countries where there are many date palm plantations. Most of the injuries happen to workers in the plantation or to children. Injuries, if detected, can be treated without subsequent complications, but in children the diagnosis can very easily be missed resulting in late complications. The hand, being the most exposed part of the body, is the most affected. Embedded thorns can produce lesions mimicking those of osteomyelitis. The foot is exposed to injuries in people who walk barefoot in the plantations. The author presents five cases of date thorn injury which presented with late complica- tions. All three patients with hand injuries had periostitis, and one of them had an intraosseous thorn producing osteomyelitis. Two patients presented with osteolytic lesions of the metatarsals with intraosseous thorn in one patient. All cases recovered completely leaving behind no sequlae of the bony infection. Key words: Hand; Metatarsal; Bone cyst; Osteomyelitis; Periostitis; Foreign body granuloma; Case Report; Oman. S S S U R E S H 348 1. W45: Foreign body or object entering through the skin 2. L92.3: Foreign body granuloma of skin and subcu- taneous tissue 3. M60.2: Foreign body granuloma of soft tissue not elsewhere classified. 4. M65: Synovitis and tenosynovitis There were 253 cases during this four year period with injuries related to foreign body intrusion in the body, of which 137 (54%) were related to injuries by date thorns. Eighty-two cases involved the upper extrem- ity, mostly the hand and fingers. Fifty-five cases were in the lower extremity, mostly involving the toes and foot. Eighteen cases of foreign body granuloma in- volving the hand and 9 cases of granulomas of the foot were excised in the operating room. The rest of the cases were managed as outpatients. X-rays were done in all cases of granulomas to rule out skeletal lesions due to date thorns. Most of the cases also underwent an ultrasound scan to localize the foreign body. There were two cases of skeletal lesions in the foot, one in a 12 year old boy. He presented with pain and swelling of the left foot of one year duration. His X- rays showed a lytic lesion of the shaft of the second metatarsal with cortical thickening. The swelling was non-tender and there were no signs of inflammation. The patient underwent curettage of the lesion under general anaesthesia and was found during surgery to have an intraosseous thorn. A lady presented with a swollen right foot, recur- Figure 1: Ultrasound scan. FB 11 mm lying 5 mm deep to skin, granuloma measuring 24 x 7.6 mm around the thorn Figure 2: X-ray of foot showing osteomyelitis of 2nd metatarsal Figure 3: CT scan of the right foot showing lytic lesion (arrow) O R T H O PA E D I C M A N I F E S TAT I O N S O F D AT E TH O R N I N J U R Y 349 ring for the past two years. She did not recollect any antecedent injury. Her X-rays of the foot were doubt- ful of a lytic lesion of the metatarsal and hence a com- puted tomography (CT) scan of the foot was done. This showed an osteolytic lesion over the base of the fourth metatarsal. The lesion was curetted and the of- fending thorn piece was removed from the intermeta- tarsal space. She eventually recovered fully. Three young people children presented with le- sions in the small bones of the hands; all boys aged 6, 11 and 16 years respectively. The boy aged 6 years was initially treated for an in- jury, and was immobilised in a slab for a short while. Later on, he presented with pain and swelling of the hand. Radiographs after few weeks showed periosteal reaction of the third metacarpal with a lytic lesion over the base of the metacarpal on the left side. The lesion healed after curettage of the lesion and removal of the offending thorn. Another boy presented with a swollen right hand after an injury with date thorn. The boy recollected the injury from a date thorn in the garden a month prior to his presentation. There was periosteal reac- tion over the entire shaft of the fourth metacarpal. The lesion healed after removal of the offending thorn and removal of the granulation tissue. Another boy had no definite history of trauma, but presented with painful swelling over the right middle finger. There was perio- steal reaction over the dorsum of the proximal pha- lanx of the middle finger. The lesion was successfully treated by curettage. No Age in years /sex Clinical details Radiology Lesion Management Histo- pathology 1 6/M Fall in garden; Pain and swelling of left hand Periosteal reaction 3rd metacarpal, lytic lesion base of metacarpal. 2.5 x 1.5 cm mobile non tender swelling dorsum of hand Curettage of the cavity, excision of granuloma Dense infiltrate of inflammatory cells, mainly neutrophils and macrophages, no foreign body giant cells 2 11/M Injury with date thorn in garden Periosteal reaction over the shaft of 4th metacarpal Soft tissue swelling dorsum of right hand Excision of granuloma, two date thorn pieces removed at surgery Inflammatory cell infiltration with foreign body giant cells 3 16/M No definite history of trauma Periosteal reaction dorsum of proximal phalanx midfinger Swollen dorsum of right middle finger Offending date thorn with granuloma removed Inflammatory cell reaction, with pieces of foreign bodies 4 12/M No definite history of trauma; swelling in dorsum of left foot of 1 year duration Osteolytic lesion over the shaft of 2nd metatarsal, with sclerotic margins Bony swelling over the dorsum of left foot, over the 2nd metatarsal Lesion curetted through a window, granuloma curetted, thorn removed Inflammatory cell reaction 5 23/F Swelling in right foot of 2 years duration Osteolytic lesion base of 4th metatarsal. Confirmed with CT scan Tender swelling dorsum of right foot over base of 4th and 5th metatarsal Thorn removed from interdigital space of 4th and 5th toes. Base of 4th metatarsal curetted Fibrocollagenous and fibroadipose tissue with inflammatory granulation tissue, with pieces of thorn Table 1: Characteristics of the date thorn injuries in the five cases S S S U R E S H 350 D I S C U S S I O N Date thorn is a modified leaf that ends in a spine of the palm tree, Phoenix anarensis, which is widely cultivated in the Middle-East countries.2 Penetrating injuries of the extremities by date thorn are common in Middle Eastern countries.2 Children are exposed to thorn injuries because of their contact with date palms in gardens or plantations. There may not be any visible signs of injury. If detected, attempts at removal may leave part of the sharp tip of the thorn inside the body. The initial symptoms are usually mild and disappear in a few days, but some patients present late with granu- loma or bony pathology.9 A diagnosis of a date thorn foreign body is considered when there is a history of trauma and a periosteal reaction or lytic lesion is seen in the radiographs. A date thorn embedded near a bone can produce a pathological reaction resulting in periostitis or osteomyelitis. A retained thorn can present as synovitis, arthritis, rheumatism, granuloma or osteomyelitis.3, 9, 11, 12, 13, 14, 15 Gerle named the pathology “thorn-induced pseu- dotumor of bone.” Maylahn called them thorn-in- duced “tumors of bone.”3, 7, 13 In most of the cases, the thorn is removed by the patients causing little morbid- ity. If retained in the tissue it can cause an inflamma- tory reaction leading to development of foreign body granulomas. A thorn stab produces an acute local inflammatory reaction in the tissues16 even if no part of the thorn remains in the body. Antibiotics are indi- cated only if the culture turns positive for a particular organism. Durr et al 6 reported a case of intraosseous thorn in the diaphysis of the fifth metatarsal in a fifty- six year old lady. Organic plant material when present in or near a bone can produce lesions in bone that are lytic or sclerotic or a combination of both. 6, 17There is usually a delay in seeking medical help or there is a delay in diagnosis with the mean time of presenta- tion in various reports of around four months.6, 9, 16 Granuloma is due to incomplete removal of the date thorn by the patient retaining the sharp tip inside the soft tissue, of which the patient is unaware. Most of the thorn related injuries occur in the hand, it being the most exposed body part. So far only eight meta- carpal lesions and three phalangeal lesions have been reported.1, 4, 6, 7, 18 The thorn, once entered, produces a granuloma by foreign body reaction, resulting in periosteal re- action or osteolysis. Once inside the joint, the thorn can cause synovitis due to a chemical reaction.14 Most children do not identify the initial injury, making the diagnosis difficult. The periosteal reaction may mimic osteomyelitis, trauma or Ewing’s sarcoma. 7, 13 If the thorn remains in the subperiosteal region this can cause a subperiosteal reaction and periosteal eleva- tion 8 Subsequent to this the cortical bone is devital- ized resulting in a sequestrum8 A periosteal reaction should also be differentiated from the periosteal reac- tion of stress fractures, as the lesions of thorn-induced skeletal changes are seen mostly in the paediatric age group. Because palm thorns are not radio-opaque, X- rays are negative for the foreign body until and unless bony lesions develop. Thorns can be seen in the tissues as echogenic structures surrounded by inflammatory hypoechoid tissue during an ultrasound scan. High performance ultrasonography is useful for preopera- tive assessment of the granuloma and for localizing the foreign body.18 As plain radiographs and even an ultrasound may not show the foreign body, a mag- netic resonance imaging (MRI) scan may have to be done.12 There are reports8 where even an MRI has failed to show the foreign body. Date thorn granuloma is usually not suppurative, unless contaminated with organic material from the farm. 9, 11, 17 Bacterial growth in date thorn injury is rare 3,12,19 Many organisms have been identified in the tissues, though bacterial growth is infrequently reported from date thorn lesions. 19 Au- thors suggest that Pantlea agglomearns should be con- sidered in aseptic arthritis of the joints after date thorn injuries. This organism is considered less aggressive and can cause protracted local inflammation 16 Date thorn palm may contain some toxic substance, probably an alkaloid substance, which causes osteo- lytic reactions in the bone 3, 9, 12, 17, 20 Kelly, in 1966, 20 was the earliest to prove that the theory, as reported by various authors, of alkaloids in the thorn was wrong as removal of the thorn cures the inflammation. The small bit of retained thorn may not contain enough al- kaloids to initiate an inflammatory response. Contrary to this, in synovitis the symptoms usually persist after removal of thorn even after partial synovectomy, and total synovectomy is needed for complete resolution.5 The speculation of alkaloids causing the granuloma is not scientifically proven yet. No microorganisms are usually grown from the tissue, and the infection that occurs is secondary.4 Yousefzadeh, in 1978, reported a case of sclerotic and lytic lesions in the fifth meta- carpal due to thorn-induced granuloma in an eight year old boy. The interval between the entry of foreign O R T H O PA E D I C M A N I F E S TAT I O N S O F D AT E TH O R N I N J U R Y 351 body and the appearance of bony changes in the ra- diographs, in the study by Yousefzadeh, ranged from three weeks to two years.15, 20 Maylahn,7 as early as 1952, suggested that thorn induced granuloma should be considered in the differ- entials of bone neoplasms. As early as 1936, Maylahn came across a date thorn injury of the fibula result- ing in a granuloma and radiological features of Ewing’s sarcoma.7 The lesion in the fourth metacarpal of a child was diagnosed by Barry1 as due to tuberculous infection. A similar case was treated by Dhillon et al17 with an- tituberculous drugs until a wooden splinter was ex- truded. Tuberculosis was considered in the differential diagnosis by various authors.1, 3, 17, 20 C O N C L U S I O N Date thorn granuloma should be kept in mind while treating extremity bone and joint infections in chil- dren in the Middle East countries. The diagnosis is easy when there is history of injury with a date thorn. The granuloma should be excised and the bone must be debrided after removal of the thorn. Appropriate antibiotics must be started after intraoperative cul- ture. Date thorn granuloma should be suspected if there are osteolytic or sclerotic lesions in the extremi- ties of children from areas where date palms are grown extensively. R E F E R E N C E S 1. Barry M, Maffulli N, Good C. The missed thorn. Acta Orthop Belg 1992; 58:468-470. 2. Suresh SS. Date thorn infections of the hand in children. J Hand Surg (Eur) 2008; 33:227-329. 3. Balasubramaniam P, Prathap K. Pseudotumous due to oil palm thorn injury. Aust N Z J Surg 1977; 47:223- 225. 4. Brady RC, Sommerkamp G. Thorn induced alteraria flexor tenosynovitis of the hand. Pediat Inf Dis J 2001; 20:1097-1098. 5. Diog SG, Cole WG. Plant thorn synovitis: Resolution following total synovectomy. J Bone Joint Surg 1990; 72B:514-515. 6. Durr HR, Stabler A, Muller PE, Refior HJ. Thorn-In- duced pseodotumor of the metatarsal: A case report. J Bone Joint Surg 2001; 83A:580. 7. Maylahn DJ. Thorn-induced “tumors” of bone. J Bone Joint Surg 1952; 34A:386-388. 8. Peters V, Rubin L, Gloster ES, Aprin H. Foreign-body osteitis of the metacarpal bone. Clin Orthop Rel Res 1992; 278:69-72. 9. Ramanathan EBS, Luiz CP. Date palm thorn synovitis. J Bone Joint Surg 1990; 72B: 512-513. 10. Vidyadhara S, Rao SK. Thorn prick osteomyelitis of the foot in barefoot walkers: a report of four cases. J Orthop Surg 2006; 14:222-224. 11. Aflatoon K, Aboulafia AJ, McCarthy E, Frassica FJ. Soft Figure 4: Date thorn infection of 3rd metacar- pal. Single arrow: lytic lesion base of metacarpal; double arrow: periosteal reaction Figure 5: Periosteal reaction of the middle pha- lanx of right middle finger S S S U R E S H 352 tissue mass in a 5-year old boy. Clin Orthop Rel Res 2003; 411:348-354. 12. Grainger AJ, Campbell RSD. Post-traumatic bone cyst: a case of the floating fragment. Skel Radiol 1998; 27: 400-402. 13. Gerle RD. Thorn-induced pseudo-tumours of bone. Br J Radiol 1971; 44:642-645. 14. Lozano-Moreno FJ. Late complications after a palm thorn injury to the hand. Eur J OrthopTraumatol 2005; 15:329-332. 15. Yousefzadeh DK, Jackson Jr JH. Organic foreign body reaction. Report of two cases of thorn-induced granu- loma and review of the literature. Skel Radiol 1978; 3:167-176. 16. Peleg R, Greenberg D. Palm tree thorn injuries - A case series of ambulatory patients. J Musculoskletal Pain 2005; 13:49-52 17. Dhillon MS, Prasanna HM, Goni V, Nagi ON, Wooden splinter-induced pseudo tumor of the metatarsal. Foot Ankle Surg 2000; 6:45-48. 18. Chijiwa T, Domoto H, Miyazaki N. The foreign body granuloma of a plant thorn preoperatively de- tected by ultrasonography. Internet J Plastic Surg 2006; From http://www.ispub.com/ostia/index. php?xmlFilePath=journals/ijps/archives.xml Accessed Feb 2008. 19. Kratz A, Greenberg D, Barki Y, Cohen E, Lisshitz M. Pantoea agglomerans as a cause of septic arthritis after palm tree thorn injury; case report and literature re- view. Arch Dis Childhood 2003; 88:542-544. 20. Kelly JJ. Blackthorn inflammation. J Bone Joint Surg 1966; 48B:474-477.