NeedlesAn IV drug user accidentally breaks off a 25-gauge needle in his/her forearm and presents to your ED for needle foreign body removal. How can you minimize the degree of trauma to the patient? How can you minimize the number of incisions made in order to find and remove this “needle in a haystack”?


Trick of the Trade

Use the Michelangelo needle-in-needle technique


OK so this isn’t the official name for the procedure, but illustrates the technique used. One of the paintings on Michelangelo’s Sistine Chapel ceiling is the Creation of Adam (seen above).

In a similar fashion, under ultrasound guidance, precisely align the tip of a large-gauge needle (14-16 gauge) to the tip of the patient’s lodged needle. Once both needles are seen in longitudinal view, you know that the needles are aligned and parallel. Now sheath (or “cap”) the smaller needle with your large-gauge needle.


White shape = provider’s large-gauge needle
Yellow line = needle foreign body
Arrow = bevel of large-gauge needle 

 Use a scalpel to cut down along the length of your large-gauge needle.



Slightly pull back on your large-gauge needle until a portion of the needle foreign body is exposed. Grab this small needle with a hemostat and remove from the patient’s body.


Thanks to Dr. Nick Villalon (UCSF-SFGH EM resident) and Dr. Nate Teisman (EM faculty) for the trick. Also thanks to Dr. Kennedy Hall (EM resident) for demonstrating in these photos.

References (added 9/12/13)

  1. Callegari L, Leonardi A, Bini A, Saturday, C, Nicotera P, Spano ‘E, Mariani D, EA Genovese, C. Fugazzola Ultrasound-guided removal of foreign bodies: personal experience. Eur Radiol. 2009 May, 19 (5) :1273-9. doi: 10.1007/s00330-008-1266-5. PMID: 19153745.
  2. Marks MW, Smith DJ Jr. Removing broken needles and other foreign objects. Postgrad Med. 1989 Feb 1;85(2):234, 236. PubMed PMID: 2915957.
Michelle Lin, MD
ALiEM Founder and CEO
Professor and Digital Innovation Lab Director
Department of Emergency Medicine
University of California, San Francisco
Michelle Lin, MD


Professor of Emerg Med at UCSF-Zuckerberg SF General. ALiEM Founder @aliemteam #PostitPearls at Bio:
Michelle Lin, MD