eMedicine Specialties > Orthopedic Surgery > Hand & Upper Extremity

High-Pressure Injection Injuries

Author: Jugpal S Arneja, MD, FRCSC, Assistant Professor, Division of Plastic Surgery, University of British Columbia; Attending Staff, Division of Plastic Surgery, British Columbia Children's Hospital
Coauthor(s): William Rennie, MD, Former Professor of Surgery, University of Manitoba; RB Turner, MD, FRCSC, Assistant Professor, Section of Plastic Surgery, University of Manitoba; W Reid Waters, MD, CM, FRCPSC, FACS, Associate Professor of Surgery, University of Manitoba; Former Head of Plastic Surgery Section, Winnipeg Regional Health Authority; Jonathan Toy, MD, Resident, Department of Surgery, Division of Plastic Surgery, University of Alberta Faculty of Medicine and Dentistry
Contributor Information and Disclosures

Updated: Jul 8, 2009

Introduction

History of the Procedure

In 1937, Rees published the first reported case of a high-pressure injection (HPI) injury to the finger. This injury involved diesel fuel.1 Prior to Rees's report, Hesse had described a similar injury in 1925.2

Frequency

Although over 100 case reports of high-pressure injection (HPI) injuries of the hand can be found in the literature, the incidence of these kinds of cases is difficult to assess. Nonetheless, a group from the University of Colorado described an estimated incidence of 1 in 600 hand injuries seen in their emergency department.3 These numbers suggest that HPI injuries to the hand are relatively common, given the widespread use of pressure machinery.

Etiology

Common substances involved in high-pressure injection (HPI) injuries include grease, which accounts for 57% of injuries (at pressures of up to 5,000-10,000 pounds per square inch [psi]), paint (up to 5,000 psi), and diesel fuel (accounting for 14% of injuries, with pressures of up to 2,000-6,000 psi).3,4,5 In a 1970 report, Kaufman compared the kinetic energy from a grease gun to a 1000-kg weight falling from a height of 25 cm.6 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.7,8,9,10,11,12,13 HPI injuries continue to be caused by an increasing number of substances, including paint, wax, molten metal, air, water, paint thinner, and other solvents.14,15

Photograph taken approximately 12 hours after a h...

Photograph taken approximately 12 hours after a high-pressure injection injury involving paint.

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Photograph taken approximately 12 hours after a h...

Photograph taken approximately 12 hours after a high-pressure injection injury involving paint.


Pathophysiology

High-pressure guns emit jet streams at pressures of up to thousands of psi. At these extreme pressures, material is forced through the skin, where diffusion can occur along fascial planes, tendon sheaths, and neurovascular bundles.16

Various mechanisms can be used to explain the clinical picture of high-pressure injection (HPI) 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.6,17,18,19 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.20 The volume of material injected into a closed space and the resultant edema can exacerbate ischemia.21

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.9

Some have suggested that the predominant mechanism of tissue damage is chemical irritation and that this is more important than ischemia. Ramos et al concluded that an injection of isotonic sodium chloride solution under high pressure into tissue does not produce a significant inflammatory reaction.19,22 Clinically, Pai et al noted that injected water did not induce extensive soft-tissue destruction, even when the injury was treated conservatively.23

Paint thinners lead to more extensive damage and may cause lipid dissolution and destruction of tissues, even when not injected under high pressure.17,24 Also, paints and paint thinners produce the most severe inflammatory responses, leading to high amputation rates.16,25 Grease has been shown to be associated with oleogranulomata formation (a reaction to foreign bodies), fistula formation, fibrosis, and poor functional outcomes.18,24,26 Joint contractures and ankylosis are also seen.3

Presentation

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 age of the patient at injury is 28.4 years, with an age range of 16-47 years.22 The left hand is twice as likely to be damaged as the right hand.3,17,27 A common explanation for this pattern is that, sometimes, inexperienced workers clean the end of a pressure gun with the tip of a finger. The injection can be painless, and the individual may continue to work16,28 ; however, these substances may be absorbed systemically and, within hours of injury, may result in fever, leukocytosis, and lymphadenitis.25,29

The entrance site from high-pressure injection (HPI) injuries is often deceptively small. The injected material acts as a projectile. The physician must look for possible exit sites as well.9 This seemingly benign appearance may lead some clinicians to send the patient home with analgesia and reassurance.30 Invariably, the patient returns to the hospital experiencing excruciating pain and unable to move the involved finger or hand.31

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.22 In the case of an air-injection injury, associated crepitus and subcutaneous emphysema are possible.21 Interestingly, Temple et al reported a case of pneumomediastinum after an injection injury to the hand.32

The severity of the injury is dependent on many factors, including the type, toxicity, temperature, amount, and viscosity of the material injected; the pressure of injection; the involvement of synovial sheaths; the anatomy and distensibility of the injection site; secondary infection; and the time interval between injury and surgery.17,33 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.29,34 In addition, the site of penetration can influence the extent of injury.33

Kaufman performed experiments on cadaver hands in which he injected wax at 750 psi.35 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. In some cases, the proximal elbow may be reached along the flexor tendon sheath.35 Injected material may also travel into the deep spaces of the hand.26

Infection following HPI 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.3,21 Amputation rates range from 16-55% for HPI injuries.3,17,22,33

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.28 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.

Indications

High-pressure injection (HPI) injuries involving grease and paint are considered surgical emergencies, whereas HPI injuries with other substances require careful clinical evaluation and/or surgical intervention.

Relevant Anatomy

See Intraoperative details.

Contraindications

Clean water and air injuries may result in good functional outcomes with simple monitoring and conservative management (see Intraoperative details). Generally, surgeons should have a low threshold for surgical management of HPI injuries because they are surgical emergencies.

More on High-Pressure Injection Injuries

Overview: High-Pressure Injection Injuries
Workup: High-Pressure Injection Injuries
Treatment: High-Pressure Injection Injuries
Follow-up: High-Pressure Injection Injuries
Multimedia: High-Pressure Injection Injuries
References
Further Reading
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References

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  2. Hesse. Die chirurgische und gerichtichmedizinische bedeutung der kunstlich hervogerufenen erkrankungen. Arch Klin Chir. 1925;136:277-91.

  3. Schoo MJ, Scott FA, Boswick JA Jr. High-pressure injection injuries of the hand. J Trauma. Mar 1980;20(3):229-38. [Medline].

  4. Peters W. High-pressure injection injuries. Can J Surg. Oct 1991;34(5):511-3. [Medline].

  5. Bandyopadhyay C, Mitra A, Harrison RJ. Ocular injury with high-pressure paint: a case report. Arch Environ Occup Health. Summer 2009;64(2):135-6. [Medline].

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  7. Klareskov B, Gebuhr P, Rordam P. Compressed air injuries of the hand. J Hand Surg [Br]. Oct 1986;11(3):436-7. [Medline].

  8. Weltmer JB Jr, Pack LL. High-pressure water-gun injection injuries to the extremities. A report of six cases. J Bone Joint Surg Am. Sep 1988;70(8):1221-3. [Medline].

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  12. Connolly CM, Munro KJ, Hogg FJ, Munnoch DA. Water-power: High pressure water jets and devastating lower limb injury. J Plast Reconstr Aesthet Surg. Mar 3 2009;[Medline].

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  37. Stark HH, Ashworth CR, Boyes JH. Paint-gun injuries of the hand. J Bone Joint Surg Am. Jun 1967;49(4):637-47. [Medline].

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  39. Bottoms RW. A case of high pressure hydraulic tool injury to the hand, its treatment aided by dexamethasone and a plea for further trial of this substance. Med J Aust. Oct 13 1962;49(2):591-2. [Medline].

  40. Dailiana H, Kotsaki D, Varitimidis S, Moka S, Bakarozi M, Oikonomou K, et al. Injection injuries: seemingly minor injuries with major consequences. Hippokratia. Jan 2008;12(1):33-6. [Medline].

  41. Wieder A, Lapid O, Plakht Y, Sagi A. Long-term follow-up of high-pressure injection injuries to the hand. Plast Reconstr Surg. Jan 2006;117(1):186-9. [Medline].

  42. Bekler H, Gokce A, Beyzadeoglu T, Parmaksizoglu F. The surgical treatment and outcomes of high-pressure injection injuries of the hand. J Hand Surg Eur Vol. Aug 2007;32(4):394-9. [Medline].

  43. Verhoeven N, Hierner R. High-pressure injection injury of the hand: an often underestimated trauma: case report with study of the literature. Strategies Trauma Limb Reconstr. Apr 2008;3(1):27-33. [Medline].

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Keywords

high-pressure injection injury, high-pressure injury, HPI injury, hand injury, finger injury

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Contributor Information and Disclosures

Author

Jugpal S Arneja, MD, FRCSC, Assistant Professor, Division of Plastic Surgery, University of British Columbia; Attending Staff, Division of Plastic Surgery, British Columbia Children's Hospital
Jugpal S Arneja, MD, FRCSC is a member of the following medical societies: American Academy of Pediatrics, American Burn Association, American Cleft Palate/Craniofacial Association, American College of Surgeons, American Society of Maxillofacial Surgeons, American Society of Plastic Surgeons, Canadian Medical Association, Canadian Society of Plastic Surgeons, and Royal College of Physicians and Surgeons of Canada
Disclosure: Nothing to disclose.

Coauthor(s)

William Rennie, MD, Former Professor of Surgery, University of Manitoba
William Rennie, MD is a member of the following medical societies: Canadian Medical Association, Canadian Orthopaedic Association, and Quebec Medical Association
Disclosure: Nothing to disclose.

RB Turner, MD, FRCSC, Assistant Professor, Section of Plastic Surgery, University of Manitoba
RB Turner, MD, FRCSC is a member of the following medical societies: Canadian Medical Association, Canadian Medical Protective Association, and Canadian Society of Plastic Surgeons
Disclosure: Nothing to disclose.

W Reid Waters, MD, CM, FRCPSC, FACS, Associate Professor of Surgery, University of Manitoba; Former Head of Plastic Surgery Section, Winnipeg Regional Health Authority
W Reid Waters, MD, CM, FRCPSC, FACS is a member of the following medical societies: American Association of Plastic Surgeons, American College of Surgeons, American Society of Plastic Surgeons, Canadian Medical Association, Canadian Society of Plastic Surgeons, International College of Surgeons, and Royal College of Physicians and Surgeons of Canada
Disclosure: Nothing to disclose.

Jonathan Toy, MD, Resident, Department of Surgery, Division of Plastic Surgery, University of Alberta Faculty of Medicine and Dentistry
Jonathan Toy, MD is a member of the following medical societies: Alberta Medical Association, American Society of Plastic Surgeons, Canadian Medical Association, and Canadian Society of Plastic Surgeons
Disclosure: Nothing to disclose.

Medical Editor

Peter M Murray, MD, Associate Professor of Orthopedic Surgery, Mayo Clinic College of Medicine; Director of Education, Mayo Foundation for Medical Education and Research, Jacksonville; Consultant, Department of Orthopedic Surgery, Mayo Clinic, Jacksonville; Consulting Staff, Nemours Children's Clinic and Wolfson's Children's Hospital
Peter M Murray, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American Association for Hand Surgery, American Orthopaedic Association, American Society for Reconstructive Microsurgery, American Society for Surgery of the Hand, Florida Medical Association, Orthopaedic Research Society, and Society of Military Orthopaedic Surgeons
Disclosure: Small Bone Innovations Workshop Honoraria Speaking and teaching

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: eMedicine Salary Employment

Managing Editor

Thomas R Hunt III, MD, John D Sherrill Professor and Director of Orthopaedic Surgery, Surgeon in Chief of UAB Highlands Hospital, Director of Hand and Upper Extremity Fellowship, University of Alabama at Birmingham
Thomas R Hunt III, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American Association for Hand Surgery, American Orthopaedic Association, American Orthopaedic Society for Sports Medicine, American Society for Surgery of the Hand, AO Foundation, Mid-America Orthopaedic Association, and Southern Orthopaedic Association
Disclosure: Tornier Consulting fee Review panel membership

CME Editor

Dinesh Patel, MD, FACS, Associate Clinical Professor of Orthopedic Surgery, Harvard Medical School; Chief of Arthroscopic Surgery, Department of Orthopedic Surgery, Massachusetts General Hospital
Dinesh Patel, MD, FACS is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American Association of Physicians of Indian Origin, American College of International Physicians, and American College of Surgeons
Disclosure: Nothing to disclose.

Chief Editor

Harris Gellman, MD, Consulting Surgeon, Broward Hand Center; Voluntary Clinical Professor of Orthopedic Surgery and Plastic Surgery, Departments of Orthopedic Surgery and Surgery, University of Miami School of Medicine
Harris Gellman, MD is a member of the following medical societies: American Academy of Medical Acupuncture, American Academy of Orthopaedic Surgeons, American Orthopaedic Association, American Society for Surgery of the Hand, and Arkansas Medical Society
Disclosure: Nothing to disclose.

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