High-Pressure Hand Injury
- Author: Stewart O Sanford, MD; Chief Editor: Trevor John Mills, MD, MPH more...
High-pressure injection injuries occur when a high-pressure injection device such as a paint or grease gun injects into the operator. Commonly, this injury occurs in the dominant hand and the index finger of the operator. However, cases involving the arms, feet, abdomen, and even cervical spine have been reported.[2, 3] Often, the injury may initially appear insignificant or benign. Future disability may be hidden behind a small, punctuate sore on the finger.[4, 5] The clinical effects of the high-pressure injection injury depend upon a number of variables, including the pressures involved, chemical toxicity, and the quantity of material injected and its temperature.
A high-pressure injection injury should be considered a surgical emergency. Immediate decompression and thorough cleansing of the offending material from the tissue is required to preserve optimal function.
Acute injury is caused by introduction of a foreign material, under high pressure between 2,000 and 10,000 psi, into the poorly distensible digital or palmar tissues. The pathophysiology involves direct trauma that may result in local tissue damage, acute and chronic inflammation, and foreign body granuloma formation. Damage results from the impact, ischemia due to vascular compression, chemical inflammation, and secondary infection. Highly viscous substances (eg, grease) require higher injection pressures than paint or solvents.
Hydrocarbon-based substances such as fuel, paint thinners, and organic solvents lead to the most severe inflammatory response with a high incidence of subsequent amputation. Grease- and oil-based compounds may lead to oleogranulomas with chronic fistula formation, scarring, and eventual loss of digit function.
Air and water injections also occur and are generally thought to be less serious because there is less resultant inflammation.
Overall incidence of amputation approaches 48%. Morbidity is dependent to a large degree upon the material injected. Paint solvents appear to cause the greatest damage and result in amputation in 60-80% of the cases. Grease, the more common injectant, causes a less severe inflammatory response. Amputation is necessary in about 25% of these patients.
These injuries are rare in women. High-pressure hand injuries usually occur in young men while working, most often to their nondominant index finger. The average age at time of injury in one large review was 35 years (range, 16-65 y). These injuries occurred to the nondominant hand 76% of the time.
Wieder A, Lapid O, Plakht Y, Sagi A. Long-term follow-up of high-pressure injection injuries to the hand. Plast Reconstr Surg. 2006 Jan. 117(1):186-9. [Medline].
Chu FY, Wu KC, Lin HJ. Craniofacial high-pressure air injection injury. Ann Emerg Med. 2007 Jan. 49(1):113-5. [Medline].
Gao X, Wu QH, Chen WS, Chen QX, Xu K, Li FC. An unusual high-pressure injection injury involving the cervical spinal cord. J Bone Joint Surg Br. 2011 Aug. 93(8):1140-2. [Medline].
Vasilevski D, Noorbergen M, Depierreux M, Lafontaine M. High-pressure injection injuries to the hand. Am J Emerg Med. 2000 Nov. 18(7):820-4. [Medline].
Sirinoglu H, Ersoy B, Bayramiçli M. Late presentation of a case of high pressure cement injection injury to the hand. J Plast Surg Hand Surg. 2013 Jul 8. [Medline].
Sarwar U, Javed M, Rahman S, Wright TC. Digital high-pressure injection injury: the importance of early recognition and treatment. BMJ Case Rep. 2014 Feb 19. 2014:[Medline].
Schoo MJ, Scott FA, Boswick JA Jr. High-pressure injection injuries of the hand. J Trauma. 1980 Mar. 20(3):229-38. [Medline].
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. 2008 Apr. 3(1):27-33. [Medline].
Gonzalez R, Kasdan ML. High pressure injection injuries of the hand. Clin Occup Environ Med. 2006. 5(2):407-11, ix. [Medline].
Vilke GM, Snyder B. High pressure paint spray gun injury. J Emerg Med. 2002 Aug. 23(2):203-4. [Medline].
Valentino M, Rapisarda V, Fenga C. Hand injuries due to high-pressure injection devices for painting in shipyards: circumstances, management, and outcome in twelve patients. Am J Ind Med. 2003 May. 43(5):539-42. [Medline].
Oktem F, Ocguder A, Altuntas N, Bozkurt M, Tellioglu AT. High-pressure paint gun injection injury of the hand: a case report. J Plast Reconstr Aesthet Surg. 2009 Jun. 62(6):e157-9. [Medline].
Amsdell SL, Hammert WC. High-pressure injection injuries in the hand: current treatment concepts. Plast Reconstr Surg. 2013 Oct. 132 (4):586e-591e. [Medline].
Kon M, Sagi A. High-pressure water jet injury of the hand. J Hand Surg [Am]. 1985 May. 10(3):412-4. [Medline].
Goetting AT, Carson J, Burton BT. Freon injection injury to the hand. A report of four cases. J Occup Med. 1992 Aug. 34(8):775-8. [Medline].
Almind M, Broeng L. A high velocity, high temperature injection injury. J Hand Surg [Br]. 1993 Apr. 18(2):249-50. [Medline].
Atkinson RE. Injection injuries of the hand: Caveat doctor. Hawaii Med J. 1989 Sep. 48(9):364-6, 395. [Medline].
Bekler H, Gokce A, Beyzadeoglu T. [Dissemination pathways in high-pressure injection injuries of the hand: an experimental animal model]. Acta Orthop Traumatol Turc. 2007. 41(2):147-51. [Medline].
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. 2007 Aug. 32(4):394-9. [Medline].
Geller ER, Gursel E. A unique case of high-pressure injection injury of the hand. J Trauma. 1986 May. 26(5):483-5. [Medline].
Harter BT, Harter KC. High-pressure injection injuries. Hand Clin. 1986 Aug. 2(3):547-52. [Medline].
Hogan CJ, Ruland RT. High-pressure injection injuries to the upper extremity: a review of the literature. J Orthop Trauma. 2006 Jul. 20(7):503-11. [Medline].
Larsen JM, Bindiger A, Sherman R, Kuschner SH. Insecticide injection injuries to both hands: a case report. J Hand Surg [Am]. 1992 Nov. 17(6):1073-5. [Medline].
Lewis HG, Clarke P, Kneafsey B, Brennen MD. A 10-year review of high-pressure injection injuries to the hand. J Hand Surg [Br]. 1998 Aug. 23(4):479-81. [Medline].
Loveday I. High-pressure injection injuries. Emerg Nurse. 2007 Nov. 15(7):22-3. [Medline].
Luber KT, Rehm JP, Freeland AE. High-pressure injection injuries of the hand. Orthopedics. 2005 Feb. 28(2):129-32. [Medline].
Mizani MR, Weber BE. High-pressure injection injury of the hand. The potential for disastrous results. Postgrad Med. 2000 Jul. 108(1):183-5, 189-90. [Medline].
Neal NC, Burke FD. High-pressure injection injuries. Injury. 1991 Nov. 22(6):467-70. [Medline].
Schnall SB, Mirzayan R. High-pressure injection injuries to the hand. Hand Clin. 1999 May. 15(2):245-8, viii. [Medline].
Soyuncu S, Bektas F, Dinc S. High-pressure air injection injury to the upper extremity. J Emerg Med. 2013 Jul. 45(1):96-8. [Medline].
Subramaniam RM, Clearwater GM. High-pressure water injection injury: emergency presentation and management. Emerg Med (Fremantle). 2002 Sep. 14(3):324-7. [Medline].