Frontal radiograph of the neck of a 17 year old girl with a bobby-pin fragment embedded deep into the left neck. Source: Nationwide Children's Hospital.

The potential impact of radiologists in the diagnosis of self-embedding behavior is very similar to their role in child abuse cases, explained William E. Shiels II, MD, of the departments of radiology and pediatrics at Nationwide Children’s Hospital in Columbus, Ohio. “Many times, the radiologist is the first physician to make the diagnosis of self-embedding behavior,” he told Health Imaging News.

“Often misdiagnosed, ignored or underreported, self-embedding behavior (SEB) is a form of self-injurious behavior involving the insertion of inanimate objects into the soft tissues, either under the skin or into muscle,” wrote Shiels and colleagues, in a study published in the June issue of Pediatrics.

Although SEB has flown under the diagnostic radar, it is an issue in cities across the U.S. “In every city we’ve ever spoken in, someone has said ‘we’ve seen that, but we just didn’t know what to call it or what to do with it.’… Self-injury is much more common than we realize or are willing to admit.”

According to Shiels, 24 percent of teenage children cut themselves. Teenagers who engage in SEB take cutting one step farther. While children who cut themselves may be depressed, SEB is associated with severe behavioral health and major psychiatric issues such as bipolar disorder, post-traumatic stress disorder and borderline personality disorder.

Designed to begin to form a clinical profile of adolescents who engage in SEB, the Nationwide Children’s Hospital study identified 11 patients in a retrospective chart review covering a three-year period from May 2005 to December 2008. The researchers described gender, age, psychiatric diagnoses; SEB age of onset, frequency and self-reported reasons and the number, type, location of and removal technique for objects.

“The most common self-reported purpose for SEB was suicidal ideation (75 percent),” the authors confirmed. Patients were most often white, teen-aged females with multiple psychiatric diagnoses.

When radiologists can accurately diagnose SEB and immediately report the diagnosis to the emergency or primary care physician, they can provide clinicians the information they need to mobilize the behavioral health team for interventions.

“By raising the red flag of diagnosis, radiologists can interrupt the cycle of self-harm and prevent these children from proceeding to suicide and [initiate treatment leading] to successful recovery,” Shiels stated.

Making the diagnosis
Diagnosing SEB and removing the foreign bodies may require a multi-modality approach and a thorough search, shared Shiels.

“Many times, the objects that young children are embedding into themselves are not visible on x-ray. Ultrasound is critical in diagnosing non-radiopaque foreign bodies such as wood, pencil fragments, plastic objects and crayons.”

Satisfaction of search also is critical in SEB cases. Patients who have embedded one foreign body may embed up to 20 items. In this study, Shiels and colleagues reported the mean number of objects embedded in a single episode was 2.4, with a range of one to 11 objects embedded. “Don’t stop looking until you are sure you have found everything,” he stated.

A final point about SEB concerns removal of the embedded foreign body. Conventional surgical practice related to the removal of foreign bodies in adult patients often dictates that the object is left in place as surgical removal is difficult and can be deforming.

In contrast, ultrasound and fluoroscopically guided removal techniques are precise and non-deforming and visualize vital structures, says Shiels. “We can remove 20 foreign bodies in one setting through openings that leave a scar the size of a freckle.”

Shiels and colleagues concluded, “Awareness of SEB is paramount for rapid and effective identification, assessment and interruption of the cycle of self-injury.” They emphasized the need for additional research including investigating specific risk and protective factors and developing evidence-based assessment instruments and multidisciplinary treatments.