On your evening ambulatory shift you receive a 35-year-old manual worker. It was the end of his shift and he got distracted and injected his index finger with fuel oil from a hydraulic pump. He presents with a minor wound to his palm. The patient complains of intense pain around the area and swelling of his palm.
Take home points
- High pressure injection injuries are a true emergency.
- The puncture wound is usually small and initially seems innocuous.
- These injuries require prompt surgical intervention with surgical debridement of all ischemic tissu.
Mechanism and presentation
These injuries are most common in laborers working with paint, automobile grease, diesel oil and solvents. The non-dominant index finger is the most commonly injured and the injuries often occur in unexperienced laborers or at the end of a shift when the worker is tired or inattentive.
To breach the skin, the ejection pressure must be at least 100 pounds per square inch (PSI). Most high pressure guns and injectors reach pressure of 2000 to 12 000 PSI. This leads to dissection along the planes of least resistance (the neuromuscular bundles) with subsequent vascular spasms and thrombosis leading to soft tissue necrosis. The fluid itself combined with edema creates a pressure buildup which can lead to compartment syndrome. Furthermore, ischemia and necrosis facilitate secondary infections.
You should be most worried of organic solvents. Industrial solvents and oil based paints cause the most damage while grease and water based paint are less destructive. The prognosis depends on the volume injected, the nature of the fluid, the force of injection and the time from injury to treatment (where we can make the difference). Amputation rates are as high as 30% highlighting the importance of identifying and properly treating these injuries.
History should focus on identifying the time since injury, pressure and substance involved. The exam should document a neurovascular exam and assess tendon integrity. Keep in mind that most of the damages are not visible to the eye. Radiographs may be used to detect spread of radio-opaque dye.
Treatment
Initial treatment should focus on tetanus prophylaxis, IV antibiotics (with gram-positive and gram negative coverage), limb elevation and getting in contact with your orthopedist or hand surgeon. A splint can be applied. Digital nerve block should be avoided. A minority might be managed conservatively but most will require immediate irrigation, debridement and foreign body removal. The risk of amputation is significantly reduced if surgery is performed within 6 hours of the injury.
By: Chanel Fortier-Tougas
References
- HZ Dailiana, D. Kotsakum S, Varitimidis, S Moka, M Bakarozi, K Oikonomou, and NK Malizos. Injection injuries: seemingly minor injuries with major consequences. Hippokratia. 2008, 12(1): 33-36
- CJ Hogan, RT Ruland. High Pressure Injection Injuries to the upper extremity: a review of the literature. Journal or Orthopedic Trauma. 2006, 20(7); 503-11
- Aiyer. High-Pressure Injection Injuries. Orthobullets.com. update 2016
- Guthrie. High Pressure-Injection Injury. lifeinthefastlane.com. update 2016
- Daverport, P Tang, Chapter 268: Injuries to the Hand and Digits, Tintinalli’s Emergency Medicine: A Comprehensive Study Guide 8th Edition
- M T.Fitch. Chapter 15: Puncture Wounds and Bites, Tintinalli’s Emergency Medicine: A Comprehensive Study Guide 8th Edition
- K C.Chung, H Yoneda. K G Modrall, Pathophysiology, classification and causes of acute extremity compartment syndrome, UpToDate.com, update 2018
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