Orthopedic Surgeons’ Nightmare: Rare Case of Retained Gauze Piece after Wrist Surgery Masquerading as Soft-Tissue Tumor

INTRODUCTION: Retention of cotton-based gauze or sponge in surgical field, variously called as gauzoma, gossypiboma, textiloma, and muslinoma, is an unexpected and untoward human error that carries sinister consequences for patients and surgeons. Although reported at various surgical sites, no such case has been reported so far in upper limb after wrist surgery. CASE REPORT: Here, we present a case of gauzoma in a 24-year-old male who was operated for his right side distal radius fracture at a private hospital. He noticed gradually increasing swelling in his forearm 6 months after operation which persisted after the removal of implant. Initial cytological evaluation suspected soft-tissue tumor and he was referred to our hospital for further management. Plain radiographic, sonographic, and magnetic resonance imaging findings could not ascertain the pathology conclusively. Surgical exploration revealed retained gauze piece surrounded by granulation tissues and membrane. Histopathological examination confirmed gauze piece with necrosis and surrounding inflammation. The patient recovered uneventfully and has had no recurrence till final follow-up. CONCLUSION: Despite uncommon condition at uncommon site, one should always have a strong suspicion of this entity at previous surgical site since it has a varied clinical and radiologic presentation. Strong vigil, strict adherence to surgical safety protocol is paramount to evade this orthopedic surgeons’ nightmare.