A 19-year-old man presents to urgent care with intense pain in his left hand after picking up a sea urchin 4 days ago along the California coast. He reports that the pain was immediate and felt “like being stabbed with hot pokers.” He rinsed his hand briefly with seawater and attempted to remove the spines himself. In the past 48 hours, pain has worsened with movement of his fingers, despite taking 440 mg ibuprofen. Localized swelling, stiffness, and tenderness over the volar aspect of the index finger and joint have also worsened. He is concerned about the skin pigmentation left behind from the spines. Patient denies numbness, weakness, fever, nausea, vomiting, dizziness, chest pain, or shortness of breath. His past medical history is unremarkable, and his vital signs are normal.
What is the most appropriate next step in management of this patient?
- Reassure the patient that spine pigmentation can persist weeks and even years, and discharge without further workup.
- Prescribe oral antibiotics and schedule routine follow-up.
- Repeat hot water immersion and prescribe topical corticosteroid therapy.
- Obtain imaging to evaluate for retained foreign bodies and refer for surgical evaluation.
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Correct answer: d. Obtain imaging to evaluate for retained foreign bodies and refer for surgical evaluation
Sea urchin spines are brittle and commonly fragment, leaving retained foreign material that can provoke chronic inflammation, granuloma formation, infection, or synovitis. Pigmentation may or may not be caused by foreign material, but delayed pain, stiffness, or loss of function after injury from a sea urchin should be assumed to be retained spine until proven otherwise. Delayed or worsening focal pain, especially near a joint, is a red flag for deep tissue involvement. In the urgent care setting, maintain a low threshold for imaging (x-ray or ultrasound) and surgical referral when joint spaces, connective tissue, or persistent symptoms are involved.
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Tracey Davidoff, MD, FACP, FCUCM, has practiced Urgent Care Medicine for more than 15 years. She is Board Certified in Internal Medicine. Dr. Davidoff is a member of the Board of Directors of the Urgent Care Association and serves as Co-Editor-in-Chief of the College of Urgent Care Medicine’s “Urgent Caring” publication. She is also the Vice President of the Southeast Regional Urgent Care Association and a member of the editorial board of the Journal of Urgent Care Medicine. At EB Medicine, Dr Davidoff is Editor-In-Chief of Evidence-Based Urgent Care, and co-host of the Urgentology podcast.
