High pressure injection injury

High pressure injection injury occurs when a high-pressure injection device such as a hydraulic oil, paint or grease gun injects material into the operator constitutes a medical and surgical emergency. A delay in treatment may result in inferior functional outcomes ¹. In the fingers, amputation rates are as high as 48% ². High pressure injection injury requires rapid access to appropriate specialist surgical review. Generally, surgeons should have a low threshold for surgical management of high pressure injection injuries ³. The high pressure injection injury is frequently worse than it will initially appear and patients must have a high level of suspicion of injury. High pressure injection injury most commonly occurs in the dominant hand and index finger ⁴. However, cases involving the arms, feet, abdomen, and even cervical spine have been reported ⁵. Most injuries result from grease guns, paint sprayers, or diesel fuel injectors ⁶. Often, the injury may initially appear insignificant or benign. Future disability may be hidden behind a small, punctuate sore on the finger ⁷. The clinical effects of the high-pressure injection injury depend upon a number of variables, including the pressures involved, chemical toxicity, and the quantity of material injected and its temperature ⁸, ⁹.

High pressure injection injuries are rare in women. High-pressure hand injuries usually occur in young men while working, most often to their nondominant index finger. The average age at time of injury in one large review was 35 years (range, 16-65 years). High pressure injection injuries occurred to the nondominant hand 76% of the time ¹⁰.

The high pressure injection injury typically occurs to the fingertip when the operator is trying to wipe clear a blocked nozzle or to the palm when the operator is attempting to steady the gun with a free hand during the testing or operation of equipment. The left hand (usually non-dominant) is involved in about two thirds of cases. The most common site of injury is the index finger. The palm and long finger are the next most frequently injured ¹¹.

The innocuous appearance of the wound may hide the severity of the injury ¹². With time, edema and intense pain develop and the digit may appear erythematous or cold.

A high-pressure injection injury should be considered a surgical emergency. Immediate decompression and thorough cleansing of the offending material from the tissue is required to preserve optimal function. Emergent consultation with an experienced hand surgeon is required. Prompt surgical debridement optimizes tissue salvage. Diagnosis is clinical and based largely on patient history. However, secondary to the surgical nature of these injuries, routine preoperative evaluation may be initiated in the emergency department. Laboratory tests may include complete blood cell (CBC) count, electrolyte values and renal function, cardiography, and chest radiography. Radiographs may facilitate the surgical strategy by localizing subcutaneous air, debris, or unanticipated fractures ¹³.

Infection following high pressure injection injuries is seen more commonly in digits that have not been treated. Ischemia and necrotic tissue are a haven for the proliferation of microbes. Coincidentally, many materials injected have antimicrobial properties ¹⁴. Amputation rates for high pressure injection injuries range from 16% to 55% ¹⁵.

Overall incidence of amputation approaches 48% ¹⁶. Morbidity is dependent to a large degree upon the material injected. Paint solvents appear to cause the greatest damage and result in amputation in 60-80% of the cases. Grease, the more common injectant, causes a less severe inflammatory response. Amputation is necessary in about 25% of these patients ¹⁰.

High pressure injection injury causes

High-pressure guns emit jet streams at pressures of thousands of pounds per square inch (psi). At these extreme pressures, material is forced through the skin, where diffusion can occur along fascial planes, tendon sheaths, and neurovascular bundles ¹⁷. Common substances involved in high pressure injection injuries include the following ¹⁸:

• Grease (accounting for 57% of injuries, at pressures of up to 5000-10,000 psi)
• Paint (up to 5000 psi; see the images below)
• Diesel fuel (accounting for 14% of injuries, with pressures of up to 2000-6000 psi)

In a 1970 report ¹⁹, Kaufman compared the kinetic energy from a grease gun to a 1000-kg weight falling from a height of 25 cm. Injuries with compressed air (at pressures of up to 50-300 psi) and high-pressure water injection (up to 6000-8000 psi) are also seen ²⁰. high pressure injection injuries continue to be caused by an increasing number of substances, including paint, wax, molten metal, air, water, paint thinner, and other solvents ²¹.

Various mechanisms can be adduced to explain the clinical picture of high pressure injection injuries. Ischemia, necrosis from high-velocity mechanical impact, the direct toxic effect of the involved chemical, and infection play major roles in these types of injuries ². Factors contributing to digital ischemia include massive vessel thrombosis from volatilization of the injected material, temporary vascular spasm as a response to trauma, venous outflow obstruction from tissue distention, and digital artery compression ²². The volume of material injected into a closed space and the resultant edema can exacerbate ischemia ¹⁴.

The chemical properties of the injected material have a considerable effect on clinical injury. With viscous substances, such as grease and oil-based compounds, dispersion is less marked than it is with more fluid materials. These substances tend not to penetrate the flexor sheath, resulting in infiltration of the surrounding neurovascular bundles. Low-viscosity solvents, such as paint thinners, may disperse more readily into the soft tissues. Injection pressure is also reported to be a factor in the extent of injury ²³.

It has been suggested that the predominant mechanism of tissue damage is chemical irritation and that this is more important than ischemia. Ramos et al ²⁴ concluded that an injection of isotonic sodium chloride solution under high pressure into tissue does not produce a significant inflammatory reaction. Clinically, Pai et al ²⁵ noted that injected water did not induce extensive soft-tissue destruction, even when the injury was treated conservatively.

Paint thinners lead to more extensive damage and may cause lipid dissolution and destruction of tissues, even when not injected under high pressure ²⁶. Also, paints and paint thinners produce the most severe inflammatory responses, leading to high amputation rates ²⁷. Grease has been shown to be associated with oleogranulomata formation (a reaction to foreign bodies), fistula formation, fibrosis, and poor functional outcomes ²⁸. Joint contractures and ankylosis are also seen ²⁹.

High pressure injection injury signs and symptoms

In cases of high-pressure injection injury, a complete history should be obtained that includes the mechanism of injury, the nature of the materials injected, the timeline, and, if possible, the pressure of the machine at the time of injury ³⁰. Following a physical examination of the involved upper extremity that notes circulation in the digit and evaluates for compartment syndrome, further investigations, such as radiographs, may be helpful.

Most frequently, the site of injury is a small puncture wound on the terminal segment of the index finger of the nondominant hand. The average patient is in their second decade of life ²⁴. The left hand is twice as likely to be damaged as the right hand ². A common explanation for this pattern is that inexperienced workers sometimes clean the end of a pressure gun with the tip of a finger. The injection can be painless, and the individual may continue to work ³⁰; however, these substances may be absorbed systemically and, within hours of injury, may result in fever, leukocytosis, and lymphadenitis ³¹.

The entrance site of an high pressure injection injury is often deceptively small. The injected material acts as a projectile. The physician must look for possible exit sites as well ²³. This seemingly benign appearance may lead some clinicians to send the patient home with analgesia and reassurance ³². Invariably, the patient returns to the hospital experiencing excruciating pain and unable to move the involved finger or hand ³³.

Depending on the volume and materials injected, the finger may be distended, swollen, and tender on palpation. If vessels in the involved digit have been thrombosed or compressed, the digit may be pale, anesthetic, or even ischemic ²⁴. In the case of an air-injection injury, associated crepitus and subcutaneous emphysema are possible ¹⁴. Interestingly, Temple et al ³⁴ reported a case of pneumomediastinum after an injection injury to the hand.

The severity of the injury is dependent on many factors, including the following ¹⁵:

• Type, toxicity, temperature, amount, and viscosity of the material injected
• Pressure of injection
• Involvement of synovial sheaths
• Anatomy and distensibility of the injection site
• Secondary infection
• Time interval between injury and surgery

With paint and other solvents, factors affecting dispersion of the material include the pressure of injection, the elasticity of tissue, and the viscosity of the substance itself ³⁵. In addition, the site of penetration can influence the extent of injury ¹⁵.

Kaufman ³⁶ performed experiments on cadaver hands in which he injected wax at 750 psi. By varying the site of injection, he discovered that injection over the fibrous tendon sheath resulted in the injected materials collecting in the tissues around the sheath, rather than within the sheath itself. When the membranous portion of the sheath was involved, the result was filling of the sheath with the injected material.

The former situation resulted in extensive neurovascular damage, with spread of the substance through loose subcutaneous tissues and into fascial planes; the latter situation caused the injected material to travel long distances ³⁶. In some cases, the proximal elbow may be reached along the flexor tendon sheath. Injected material may also travel into the deep spaces of the hand.

High pressure injection injury complications

Complications associated with high pressure injection injuries include the following:

• Infection
• Tenodesis
• Contracture
• Amputation
• Chronic pain
• Poor wound healing
• Abnormal scarring
• Limb dysfunction

High pressure injection injury diagnosis

In cases of high-pressure injection injury, a complete history should be obtained that includes mechanism of injury, materials injected, timeline, and pressure of machine at the time of injury.

The physical examination should include circulation in the digit and evaluation for compartment syndrome.

Radiographs may be helpful to help facilitate the surgical strategy by localizing subcutaneous air, debris, or unanticipated fractures ¹³.

The entrance site of an high-pressure injection injury is often deceptively small, and the injected material acts as a projectile. The physician must look for possible exit sites as well. Some clinicians may send the patient home with analgesia and reassurance because the injury seems benign, only to have the patient return to the hospital with excruciating pain and and an inability to move the involved finger or hand ¹².

Depending on the volume and type of materials injected, the finger may be distended, swollen, and tender on palpation. If blood vessels have been thrombosed or compressed, the digit may be pale, anesthetic, or even ischemic. Associated crepitus and subcutaneous emphysema are possible in cases of an air-injection injuries.

Emergency department care for high-pressure injection hand injuries includes the following:

• Obtain radiographs.
• Prescribe broad-spectrum prophylactic antibiotics.
• Update tetanus and administer parenteral analgesics.
• Splint the extremity and keep it elevated.

Some studies have suggested that steroids may be beneficial in selected cases, especially when an intense inflammatory response develops or treatment is delayed.

Imaging studies

Preoperative radiography can help delineate the extent of the tissue involved and facilitate the planning of incisions and debridement. On radiography, marked soft-tissue swelling is visible in the involved hand.

With radiopaque paint (especially lead-based paints) and grease (many commercial forms of grease have a lead component to prevent dissolution of lubrication), a random array of substances dispersed throughout the neurovascular bundles, synovial tendon sheaths, and lumbrical and interosseous muscles may be seen. Injected water may result in air densities on radiography. Some substances may be radiolucent ²⁶.

Magnetic resonance imaging (MRI) can also show dispersion of injected materials in most circumstances; however, MRI is rarely required for assessing high-pressure injection injuries.

High pressure injection injury treatment

Initial treatment of high-pressure injection injury includes tetanus prophylaxis, intravenous (IV) broad-spectrum antibiotics, and consultation with a hand surgeon ³⁷. Injections with air, gas, or small amounts of veterinary vaccines can usually be managed with observation and serial examinations if there is no concern about compartment syndrome. Injections with other liquid materials may require emergent surgical débridement, with the best results when the injury is treated within 6 hours. Wide surgical irrigation and debridement of necrotic tissues should be performed under general or regional anesthesia. Organic and caustic materials are associated with a higher amputation rate, and decreasing the time from injury to surgery improves the prognosis ³⁷.

Extravasation of the injected material may further jeopardize the limb. Prompt decompression and directed debridement of the nonviable tissue is an important strategy to prevent further tissue damage. Less-aggressive therapy may have a role in injection injuries with less irritating substances (eg, Freon) ³⁸. High-pressure injection injuries involving grease and paint are considered surgical emergencies, whereas high-pressure injection injuries with other substances require careful clinical evaluation, surgical intervention, or both. Clean water and air injuries may result in good functional outcomes with simple monitoring and conservative management ³⁹.

A retrospective review of 19 high-pressure water-injection injuries of the hand reported that 16% of patients developed infection and that 33% of patients without early debridement eventually required surgery, including debridement of a septic flexor tenosynovitis, fingertip amputation, and metacarpophalangeal disarticulation ¹³. The authors noted that high-pressure water-injection injuries warrant immediate medical attention, early antibiotics, and a low threshold for close observation or surgical debridement ¹³.

Surgical treatment

High-pressure injection injuries are considered surgical emergencies. Surgical consultation should be obtained quickly. Pai et al ²⁵ suggested that the time interval from injury to treatment is a determinant of the eventual result.

As with other hand injuries, the extremity should be elevated and splinted. With high pressure injection injuries, ice should not be used as a treatment, because it promotes vasoconstriction and further exacerbates poor circulation ⁴⁰.

Grease, paint, and other chemical injuries

After the procedures mentioned above, wide surgical decompression with timely debridement of necrotic tissue and foreign material is essential. The patient should be under general anesthesia. Affected digits should be opened by using a Brunner incision or midlateral incision through their entire length ³¹. If material is adherent to the neurovascular bundles and cannot be removed, it should be left in place ⁴¹.

Intraoperatively, an Esmarch bandage should be avoided for hemostasis because the increased pressure spreads injected materials deeper into the subcutaneous tissues. The use of solvents other than isotonic sodium chloride solution for irrigation of a wound is not recommended ⁴². Furthermore, digital or local nerve blocks are contraindicated because they increase compartment pressures and are associated with poorer outcomes ⁴³.

Returning to the operating room for further irrigation and debridement is recommended, and the wound should be left open ⁴⁰. The use of negative-pressure wound therapy for these injuries has been described ⁴⁴.

Amputation rates range from 16% to 55% for high pressure injection injuries ²⁹. Some physicians advocate amputation if the damage is severe and paint was injected into a digit. If a digit is initially cool or poorly perfused, consider early amputation ².

Because inflammation plays a key role in the extent of damage following high pressure injection injuries, adjunctive use of steroids has been suggested for severe cases. Bottoms described using dexamethasone as an adjunct ⁴⁵. Since then, others have concurred with the use of high-dose systemic corticosteroids for high pressure injection injuries, despite the theoretically increased risk of sepsis resulting from immunosuppression.

Lewis et al ² recommended that “steroids should be used with antibiotic coverage in all cases, with the exception of grease gun injuries with minimal tissue extension.” They argued that the organic chemicals usually injected generally do not support bacterial growth.

Clean water and air injuries

In contrast to high pressure injection injuries with materials such as paint, grease, and other solvents, clean water and air injuries may result in good functional outcomes with simple monitoring and conservative management.

In a 1991 report, Peters ⁴⁶ suggested that, because of the clean and relatively nonirritating nature of the water supply in the city where the injuries were reported, aggressive surgical debridement was not warranted; however, if water from a polluted source is involved, immediate surgical exploration is warranted. high pressure injection injuries with air have also been described as having a benign course ⁴⁷.

Postoperative Care

With all high pressure injection injuries, physiotherapy in the early post-injury period is imperative for a good functional outcome. Along with this treatment, swelling has been found to respond well to the application of custom-made intermittent-pressure garments ³².

A retrospective study of high pressure injection injury to the hand by Chaput et al ⁴⁸ suggested that performing a systematic “second look” 48-72 hours after initial debridement surgery may be useful in that it permits additional washing or debridement and gives the surgeon the option of performing a more conservative initial procedure.

Long-term monitoring

Follow-up care should revolve around physical and occupational therapy, social work, and the psychosocial services team, in addition to close follow-up by the hand surgeon. Once maximum physical and occupational therapy and optimal splinting have been achieved by the patient, secondary surgical procedures should be considered. Capsulotomy, neurolysis, tenolysis, and soft-tissue reconstruction are all procedures that can be considered for restoring maximal function ².

High pressure injection injury prognosis

Factors that determine the severity of high pressure injection injury include the following:

• Type and viscosity of the material injected.
• Time interval between injury and treatment.
• Amount of material injected and velocity of the injectant.
• Pressure of the appliance.
• Anatomy and distensibility of the site of injection.
• Presence of secondary infection.

Injection of irritating substances under high pressure has the potential for disability and amputation despite prompt aggressive therapy. Overall, high pressure injection injuries result in significant impairment of function and reintegration into the work force, as well as aesthetic deformity. The most common long-term impairments include cold intolerance and hypersensitivity; however, grip strength, pinch, range of motion, and two-point discrimination are also affected ⁴¹.

A case series of 8 patients with high-pressure injection injury to their hand who underwent surgical debridement, reported long-term outcomes that included the following ⁴⁹:

• Reduced range of motion of the affected digit (50%).
• Injury sequelae adversely affected activities of daily living with an average QuickDASH score of 26.
• Grip strength in the injured hand was reduced by an average of 35% in 6 out of 8 patients compared with the uninjured hand.
• Sensation was also reduced in the affected digit in 7 out of 8 patients.
• All patients suffered from some level of neuropathic pain and/or cold intolerance.

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