High-Pressure Injection Injuries - Overview

I.Definition 

A.The inadvertent introduction under pressure of paint, grease, oil, or other liquid into the fingers or the hand leads to local superficial and deep tissue necrosis, vascular and neurological embarrassment, and an urgent/emergent need for surgical assessment and treatment.

B.High-pressure injection injuries of any liquid (organic, inorganic, or water soluble) are an indication for an emergent surgical consultation for the consideration of possible incision, drainage, debridement, and irrigation. These surgical treatments may need to be repeated several times over a short period of time (sometimes daily) in order to achieve adequate wound debridement. After an adequate wound bed has been created, provision of soft tissue coverage in the form of either skin grafts or flaps (local or distant) may be necessary.

II.Pathogenesis

A.Both local pressure effects on tissue perfusion and direct tissue destruction from the noxious injectate are etiologic in tissue destruction. A secondary inflammatory reaction to the presence of paint or lubricating oils injected under high pressure has been cited as well in ongoing tissue damage.

B.Patients at their job <6 months are represented highly in this group of patients.

III.Factors Related to Outcome

A.Outcomes are worse for injection into fingers than into the palm.

B.Paint injections do more poorly than oil or grease injections.

C.Volume of injectate may be related to a poorer outcome.

D.Early surgical treatment may not necessarily lead to improved outcome but the interval between injury and surgical treatment has been considered a “major factor” in ultimate result.

E.Patients’ function is eventually better if the amputations are carried out earlier in the course of treatment.

IV.Use of Steroids

Although advocated by some providers, there is no evidence-based support for its widespread use.

V.Radiography 

A.Mandatory. 

B.Injectate is often not radio-opaque. 

C.Plain radiographs cannot determine the deep tissue involvement or the location of the injectate, but should be obtained to rule out underlying bony injury.

VI.Physical Examination

A.Small puncture wound often at the tip of the index or middle finger.

B.Wound may express injectate.

C.Variable amount of swelling in finger, palm, related to injectate (paint and lubricating oils are more inflammatory) and possible time elapsed since injection.

D.Injected material may extend down flexor sheath into palm.

E.Evaluate median nerve sensation for injections into the palm, thumb, index, middle, or ring fingers; evaluate ulnar nerve for injections into the ulnar side of the hand and small finger.

F.Gross ulnar artery or radial artery involvement is uncommon.

G.Small entry wound in a patient who presents early following injection may belie the injury severity and lead to delay in diagnosis and treatment.

VII.Treatment 

A.Wide exposure of the injected area through extensile exposures (either midlateral or Bruner).

B.Debridement of all dead and devitalized tissue while attempting to preserve longitudinal neurovascular structures of the digit as well as A2 and A4 pulleys if possible.

C.Surgical excision of all foreign material and granulomata.

D.Irrigation of all exposed tissues with saline by gravity only (use of pulse lavage irrigation is discouraged in this situation).

E.Release of the carpal canal and/or Guyon canal if appropriate.

F.Loose wound closure only (coverage of gliding tissues and neurovascular elements only).

G.Antibiotics should be given prophylactically (empiric suggestion, although not evidence based).

H.Tetanus status should be assessed (Td intramuscular injection if uncertain immunization status within the past 10 years; tetanus antitoxin for prophylaxis after injury in nonimmune or partial immune persons may be given 3,000–5,000 units subcutaneously or intramuscularly).

VIII.Compartment Syndrome

If suspected and confirmed by intra-muscular pressure assessment, then surgical decompression of the finger, the compartments of the hand (thenar, hypothenar, adductor, and interosseous), as well as carpal tunnel, Guyon canal, and forearm are completed as necessary.

IX.Postoperative Care

A.Keep all gliding tissues moist.

B.Frequent debridement and return to the operating room.

C.Provision of a stable durable soft tissue cover (full thickness skin graft, local pedicle, or island pedicle flaps can work well in the finger if vascular embarrassment is minimal; flag flaps or cross-finger flaps also can be utilized).

D.Early active, active-assisted, and passive range of motion stressing tendon gliding, and digital edema control.

X.Epinephrine Injection

A.In contrast to earlier dogma, injection of epinephrine into the finger does not routinely cause necrosis and if the digit is well-perfused prior to the injection, no treatment is typically necessary.

B.Phentolamine digital block recommended if following high concentration (1:1000) epinephrine injection into finger (5 mg in 9 cc of normal saline).

C.Repeated administration q30 minutes until ischemia resolves. 

D.If no reversal of ischemia, angiogram with intra-arterial asodilators (reserpine).

E.If intra-arterial reserpine is ineffective, surgical incision, and topical lidocaine, and papaverine (or similar vasodilator).

F.If phentolamine is unavailable, terbutaline may is used instead (1 mg in 10 cc of NS proximally; 1 mg in 1cc NS for persistent distal ischemia).

Key Article

Pappou IP, Deal DN. High-pressure injection injuries. J Hand Surg Am. 2012;37(11):2404–2407.

High-Pressure Injection Injuries Learning Module