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Updated: Jun 23 2021

High-Pressure Injection Injuries

Images injection.jpg pressure.jpg injection.jpg
  • Summary
    • High-Pressure Injection Injuries are a traumatic condition characterized by extensive soft tissue damage associated with a benign high-pressure entry wound.
    • Diagnosis requires obtaining a careful history and inspection of the digit involved.
    • Treatment involves emergent surgical debridement.
  • Epidemiology
    • Incidence
      • relatively rare, 1 in 600 hand traumas
    • Demographics
      • most common in young male laborers in industry using paint, automotive grease, solvents and diesel oil
    • Anatomic location
      • the non-dominant index finger is the most commonly affected digit
        • >50%
  • Etiology
    • Pathophysiology
      • mechanism of injury
        • injection force delievered from 3,000 to 10,000 PSI and up to 400 MPH
          • 100 PSI is enough force to break the skin
      • pathophysiology
        • 4 main components
          • initial injury 
          • chemical irritation 
          • inflammation 
          • secondary infection
      • pathoanatomy
        • leads to dissection along planes of least resistance (along neurovascular bundles)
        • vascular occlusion may lead to local soft tissue necrosis
  • Presentation
    • History
      • important to document duration since event
        • time to physician evaluation averages nearly 9 hours
      • material injected
    • Symptoms
      • minimal or no pain at injection site
      • pain and paresthesias eventually occur
    • Physical exam
      • inspection
        • entry wound often benign looking
          • only 1 in 4 initially present to ED
        • eventually finger becomes bloated, edematous, tense, pale, and cold
  • Imaging
    • Radiographs
      • may be useful to detect spread of radio-opaque dyes or paint
  • Diagnosis
    • Clinical
      • diagnosis is made with careful history and physical examination
  • Treatment
    • Nonoperative
      • tetanus prophylaxis, parenteral antibiotics, limb elevation, early mobilization, monitoring for compartment syndrome
        • indications
          • for injection of air, water, or chicken vaccine
        • outcomes
          • 50% of injuries treated nonoperatively will ultimately require an operation
          • delayed surgical management associated with higher reoperation rates and postoperative complications
    • Operative
      • irrigation & debridement, foreign body removal and broad-spectrum antibiotics
        • indications
          • most cases require immediate surgical debridement
        • outcomes
          • higher rates of amputation are seen when surgery is delayed greater than 10 hours after injury
          • 48% of finger injuries require amputation
  • Technique
    • Tetanus prophylaxis, parenteral antibiotics, limb elevation, early mobilization, monitoring for compartment syndrome
      • considerations
        • tetanus prophylaxis
        • parenteral antibiotics
          • gram-negative and gram-positive coverage
        • limb elevation
        • early mobilization
        • pain control
          • avoid digital blocks and ice to prevent decreased perfusion
        • monitor for compartment syndrome
    • Irrigation & debridement, foreign body removal and broad-spectrum antibiotics
      • approach
        • Bruner palmar digital incisions
        • midaxial incision
          • full exposure to zone of injury
      • technique
        • wide debridemeent of all involved tissues
        • decompression of tissue compartments
        • exploration and incision of tendon sheaths
        • removal of all injected material
        • saline irrigation
        • repeat I&D at 24 to 72-hours
      • complications
        • postoperative infection
          • 42% have positive cultures, most polymicrobial
  • Complications
    • Amputation
      • amputation rates approach 50% with oil-based paint injection injuries
    • Infection
      • delayed treatment increases risk of postoperative infection
      • necrotic tissue is a good culture medium for bacterial growth
      • might be lower with organic solvent injections as they do not support bacterial growth
  • Prognosis
    • Up to 50% amputation rate for organic solvents (paint, paint thinner, diesel fuel, jet fuel, oil)
    • Prognostic variables
      • time from injury to treatment
      • force of injection
      • volume injected
      • composition of material
        • grease, latex, chloroflourocarbon & water based paints are less destructive
        • industrial solvents & oil based paints cause more soft tissue necrosis
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