High-Pressure Injection Injuries - Posttest


1. The risk of amputation in high-pressure injection wounds to the hand is:

A. Less than 10%
B. Lower with injection of organic solvents
C. Lower with the adjunct use of steroids
D. Higher if infection occurs
E. Higher with injection in the finger

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Discussion: High-pressure injections in the hand and upper extremity are extremely serious and carry a significant incidence of morbidity to the patient. Aggressive surgical debridement and repeated surgeries are often necessary.  Early surgical treatment (within six hours) is associated with lower amputation risk. Hogan and Ruland performed a literature review of these injuries and found that the amputation rate was approximately 30%. In addition, injection with organic solvents like gasoline, paint thinner, oil, or jet fuel carried a higher risk of amputation. The adjunct use of steroids did not affect amputation rate or incidence of infection. In addition, the presence of infection did not appear to affect the incidence of amputation. The location of injection (i.e., in the fingers) was associated with increased amputation rates.

References:
1. Hogan CJ, Ruland RT. High-pressure injection injuries to the upper extremity: A review of the literature. J Orthop Trauma 2006; 20:503-511.
2. Pinto et al. High-pressure injection injuries of the hand: review of 25 patients managed by open wound techniques. J Hand Surg 1993;18:125-30.

 

2. A 26 year-old male presents to the emergency room one hour following an industrial paint gun injury involving the tip of the long finger as shown in Figure 1. Examination demonstrates a 3mm entrance wound at the tip of the digit. Mild swelling of the digit, hand and distal forearm is identified. Sensation of the digit is intact with capillary refill < 3 seconds.

Figure 1.

What is the recommended treatment?

 

A. Admission to the hospital with elevation of the arm and intravenous antibiotics
B. Irrigation of the wound in the emergency room and discharge home
C. Exploration of the digit in the operating room with debridement and irrigation
D. Placement of the hand into a splint and instruct on local wound care
E. Initiate wet to dry dressing changes, oral antibiotics with re-evaluation within 24 hours.

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Discussion:  Substantial soft tissue damage may occur as a result of high-pressure injection injuries. The extent of the injury may be underestimated at the time of initial evaluation. Immediate exploration with radical debridement is indicated in moderate to high-pressure injection cases (guns) and with materials such as solvents or paint.  In this case the patient has a history of exposure to paint with exam findings concerning for proximal extension and some diminished vascular status.  The risk for amputation is elevated with delay in treatment > 6 hours, the type of injected material (organic solvents) and higher pressure guns. (Figure 2, Table 1)



 

 

Journal of Hand Surgery (British and European Volume, 2005) 30B: 6: 588–592

 

References:

1. Pappou IP, Deal DN. High-pressure injection injuries. J Hand Surg Am. 2012; 37(11):2404-2407.
2. Hogan CJ, Ruland RT. High-pressure injection injuries to the upper extremity: a review of the literature. J Orthop Trauma. 2006;20:503-511.
3. Bekler H, Gokce A, Beyzadeoglu T, Parmaksizoglu F. The surgical treatment and outcomes of high-pressure injection injuries of the hand. J Hand Surg. 2007;32B:394-399.
4. Wong TC, Ip FK, Wu WC. High-pressure injection injuries of the hand in a Chinese population. J Hand Surg. 2005;30B:588-592.

3. Which of the following in high-pressure injection injuries have the highest risk of amputation?

A. Hydraulic fluid
B. Grease
C. Water
D. Air
E. Organic solvents

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Discussion:  The severity of high-pressure injection injuries in the hand are often underestimated due to the small size of the entrance wound.  Organic solvents (i.e., paint, paint thinner, gasoline, oil) have the highest risk of amputation. Patients injected with latex paints fared better than oil-based paint.   Hydraulic fluid produces less of an inflammatory response than organic solvents.

References:
1. Pappou IP, Deal DN.  High-pressure injection injuries. J Hand Surg 2012; 37A: 2404-2407.
2. Schnall SB, Mirzayan R. High-pressure injection injuries to the hand. Hand Clin.1999; 15: 245-248.

4. The amputation rate following a high-pressure injection of organic solvents is:
A. <10%
B. 10% - 20% 
C. 20% - 30% 
D. 30% - 40% 
E. >40%

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Discusssion:  High-pressure injection injuries to the hand can have devastating effects. The force delivered can range from 3,000 to 10,000 psi, with velocities up to 400 mph. These high-pressure jets can penetrate and infiltrate the subcutaneous tissues even without direct bodily contact. The force of the injection leads to tissue dissection along the planes of least resistance, which tend to follow neurovascular bundles. Amputation is required in >40% of cases involving organic solvents (paint thinner, paint, diesel fuel, gasoline, jet fuel and oil). Prompt wide surgical debridement is critical to long term preservation of tissue and restoration of function. Initial management also includes tetanus prophylaxis, empiric antibiotics, elevation of limb and analgesics. Avoid digital blocks which can lead to increased local swelling and vasospasm. Avoid ice to optimize perfusion of injected hand. Nonsurgical treatment is reserved only for
injections of air or water, which are managed expectantly, monitoring for compartment syndrome.

References:
1. Rosenwasser MP, Wei DH. High-pressure Injection Injuries to the Hand. J Am Acad Orthop Surg. 2014;22(1):38-45.
2. Ioannis PP, Deal DN. High-Pressure Injection Injuries. J Hand Surg Am. 2012;37(11):2404-2407.

5. In a 32-year-old patient presenting 24 hours after sustaining a high-pressure injection injury (3000 psi) with a paint gun (Figures 1 and 2), the factor contributing most to morbidity is:

A. Latex paint
B. Pressure setting of 3000 psi
C. Age of the patient
D. Delay in presentation
E. Handedness

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Discussion:  The first report of high-pressure injection injury was by Hesse in 1925. Most physicians recognize this injury as a surgical emergency, although the wound may be small and innocuous. The tissue damage is usually extensive, and amputation rates are as high as 48%.
The most common presentation is a young individual involving the non-dominant hand. Initially, patients may not appear symptomatic and may continue to work or present late. Excruciating pain and swelling develops over time depending on the type and amount of material injected.
Several factors have been identified that determine prognosis of these injuries:
1. Type of material, paint being more toxic than grease, and oil-based worse than water based
2. Pressure of injection. Pressures greater than 7000 psi was found to have 100% amputation rates.
3. Time from injury to treatment. Patients treated within 10 hours of injury had better results.

The key to the treatment of injection injuries lies in prompt recognition and aggressive debridement and decompression, along with serial washouts. Tetanus immunization, broad spectrum antibiotic prophylaxis due to extensive contamination, and tissue destruction is also recommended.

References:
1. Stark HH, Wilson JN, Boyes JH. Grease gun injuries of the hand. J Bone Joint Surg Am. 1961;43(4):485-491.
2. Schoo MJ, Scott FA, Boswick JA Jr. High-pressure injection injuries of the hand. JTrauma. 1980;20(3):229-238.
3. Schnall SB, Mirzayan R. High-pressure injection injuries to the hand. Hand Clin. 1999;15(2):245-248, viii.