eMedicine Specialties > Emergency Medicine > Trauma & Orthopedics

Hand Injury, High Pressure

Glen Vaughn, MD, Director, Department of Emergency Medicine, Defiance Hospital

Updated: Oct 1, 2009

Introduction

Background

A high-pressure injection injury should be considered a potential surgical emergency. Immediate decompression and thorough cleansing of the offending material from the tissue is required to preserve optimal function.

Pathophysiology

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 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.

Fuel and paint injections 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.

Mortality/Morbidity

Overall incidence of amputation approaches 48%.¹ 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.²

Sex

These injuries are rare in women.

Age

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.²

Clinical

History

The injection typically occurs to the fingertip when the operator is trying to wipe clear a blocked nozzle or to the palm when the operator is attempting to steady the gun with a free hand during the testing or operation of equipment.^3,4
The left hand (usually nondominant) is involved in about two thirds of cases.
The most common site of injury is the index finger.
The palm and long finger are the next most frequently injured.

Physical

The innocuous appearance of the wound may hide the severity of the injury.^5,1
With time, edema and intense pain develop and the digit may appear erythematous or cold.

Causes

Most injuries have resulted from grease guns, paint sprayers, or diesel fuel injectors. The cause of injury in one case report was from a high-pressure paint gun.⁶

Workup

Laboratory Studies

Perform standard preoperative laboratory tests.

Imaging Studies

Preoperative radiographs may facilitate the surgical strategy by localizing subcutaneous air, debris, or unanticipated fractures.

Treatment

Emergency Department Care

Emergency department care for high-pressure hand injuries includes the following:

Obtain radiographs.
Prescribe broad-spectrum prophylactic antibiotics.
Update tetanus and administer parenteral analgesics.
Splint the extremity and keep it elevated.
Several authors report that steroids may be beneficial in selected cases, especially when an intense inflammatory response develops or treatment is delayed.

Consultations

Refer these patients emergently to an experienced hand or orthopedic surgeon. Prompt surgical debridement optimizes tissue salvage.

Medication

The goal of therapy is to prevent infections. Prophylactic broad-spectrum antibiotics are indicated.

Antibiotics

Therapy must cover all likely pathogens in the context of the clinical setting.

Cefazolin (Ancef, Kefzol, Zolicef)

DOC; first-generation semisynthetic cephalosporin which, by binding to one or more penicillin-binding proteins, arrests bacterial cell wall synthesis and inhibits bacterial growth. Primarily active against skin flora, including Staphylococcus aureus.

Dosing

Adult

1 g IV/IM q6-8h for 5-7 d

Pediatric

25-50 mg/kg/d IV/IM divided tid/qid for 5-7 d

Interactions

Probenecid prolongs effect; aminoglycosides may increase renal toxicity; may yield false-positive urine dip test for glucose

Contraindications

Documented hypersensitivity

Precautions

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

Precautions

Adjust dose in renal impairment; superinfections and promotion of nonsusceptible organisms may occur with prolonged use or repeated therapy

Trimethoprim/sulfamethoxazole (Bactrim, Bactrim DS)

Inhibits bacterial synthesis of dihydrofolic acid by competing with para-aminobenzoic acid, inhibiting folic acid synthesis and thus bacterial growth. Antibacterial activity of TMP-SMZ includes common urinary tract pathogens except Pseudomonas aeruginosa.

Dosing

Adult

160 mg TMP or 800 mg SMZ PO q12h for 5-7 d

Pediatric

<2 months: Not recommended
Infants and children >2 months: 15-20 mg/kg/d (TMP dose) PO divided tid/qid for 5-7 d

Interactions

May increase PT when used with warfarin (perform coagulation tests and adjust dose accordingly); coadministration with dapsone may increase blood levels of both drugs; diuretics increase incidence of thrombocytopenia purpura in elderly; may increase phenytoin levels; may potentiate effects of methotrexate in bone marrow depression; may increase hypoglycemic response to sulfonylureas; may increase levels of zidovudine

Contraindications

Documented hypersensitivity; megaloblastic anemia due to folate deficiency
Do not administer to infants <2 mo

Precautions

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Discontinue at first appearance of skin rash or sign of adverse reaction; obtain CBCs frequently; discontinue therapy if significant hematologic changes occur; goiter, diuresis, and hypoglycemia may occur with sulfonamides; prolonged IV infusions or high doses may cause bone marrow depression (if signs occur, give 5-15 mg/d leucovorin); caution in folate deficiency (eg, chronic alcoholics, elderly, those receiving anticonvulsant therapy, or those with malabsorption syndrome); hemolysis may occur in G-6-PD-deficient individuals; AIDS patients may not tolerate or respond; caution in renal or hepatic impairment (perform urinalyses and renal function tests during therapy); give fluids to prevent crystalluria and stone formation

Clindamycin (Cleocin)

Lincosamide useful as treatment against serious skin and soft-tissue infections caused by most staphylococci strains. Also effective against aerobic and anaerobic streptococci, except enterococci.

Dosing

Adult

600-1200 mg/d IV/IM divided q6-8h for 5-7 d

Pediatric

20-40 mg/kg/d IV/IM divided tid/qid

Interactions

Increases duration of neuromuscular blockade induced by tubocurarine and pancuronium; erythromycin may antagonize effects; antidiarrheals may delay absorption

Contraindications

Documented hypersensitivity; regional enteritis; ulcerative colitis; hepatic impairment; antibiotic-associated colitis

Precautions

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

Precautions

Adjust dose in severe hepatic dysfunction; no adjustment necessary in renal insufficiency; associated with severe and possibly fatal colitis

Tetracycline (Sumycin)

Treats susceptible bacterial infections of both gram-positive and gram-negative organisms, as well as infections caused by Mycoplasma, Chlamydia, and Rickettsia species. Inhibits bacterial protein synthesis by binding with 30S and possibly 50S ribosomal subunit(s) of susceptible bacteria.

Dosing

Adult

250-500 mg PO q6h

Pediatric

25-50 mg/kg/d PO divided q6h

Interactions

Bioavailability decreases with antacids containing aluminum, calcium, magnesium, iron, or bismuth subsalicylate; can decrease effects of oral contraceptives, causing breakthrough bleeding and increased risk of pregnancy; can increase hypoprothrombinemic effects of anticoagulants

Contraindications

Documented hypersensitivity; severe hepatic dysfunction

Precautions

Pregnancy

D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus

Precautions

Photosensitivity may occur with prolonged exposure to sunlight or tanning equipment; reduce dose in renal impairment; consider drug serum level determinations in prolonged therapy; use during tooth development (last one half of pregnancy through age 8 y) can cause permanent discoloration of teeth; Fanconilike syndrome may occur with outdated tetracyclines

Amoxicillin (Amoxil, Biomox, Trimox)

Interferes with synthesis of cell wall mucopeptide during active multiplication, resulting in bactericidal activity against susceptible bacteria.

Dosing

Adult

250-500 mg PO q8h; not to exceed 3 g/d

Pediatric

20-50 mg/kg/d PO divided q8h

Interactions

Reduces efficacy of oral contraceptives

Contraindications

Documented hypersensitivity

Precautions

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

Precautions

Adjust dose in renal impairment

Follow-up

Further Inpatient Care

Extravasation of the injected material may further jeopardize the limb.
Prompt decompression and directed debridement of the nonviable tissue is an important strategy to prevent further tissue damage.
Less-aggressive therapy may have a role in injection injuries with less irritating substances (eg, Freon).^7,8

Further Outpatient Care

Outpatient management of high-pressure hand injuries is contraindicated.

Transfer

Transfer patient to a facility with a hand specialist if none is available at the receiving hospital.

Complications

Amputation is more likely if debridement is delayed more than 10 hours, especially with low viscosity substances.
Tissues that survive the initial injection injury but still contain grease, paint, or oil heal slowly and may develop multiple oleogranulomas of varying sizes.
In time, the oleomas drain through sinuses or open directly through the skin.

Prognosis

Factors that determine the severity of the injury
- Type and viscosity of the material injected
- Time interval between injury and treatment
- Amount of material injected and velocity of the injectant
- Pressure of the appliance
- Anatomy and distensibility of the site of injection
- Presence of secondary infection
Injection of irritating substances under high pressure has the potential for disability and amputation despite prompt aggressive therapy.

Miscellaneous

Medicolegal Pitfalls

This injury is a common cause of litigation when evaluated by the unwary physician.
The innocuous appearance of the wound obscures the potential severity of the injury.
Without diagnosis and treatment, a compartment syndrome with subsequent necrosis usually destroys tissue viability.

Special Concerns

A digital block for pain control, via injection of the finger, is contraindicated. Unlike a metacarpal block, this technique may increase tissue distention and vascular insufficiency.

References

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Vilke GM, Snyder B. High pressure paint spray gun injury. J Emerg Med. Aug 2002;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. May 2003;43(5):539-42. [Medline].
Dailiana H, Kotsaki D, Varitimidis S, Moka S, Bakarozi M, Oikonomou K. Injection injuries: seemingly minor injuries with major consequences. Hippokratia. Jan 2008;12(1):33-6. [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. Jun 2009;62(6):e157-9. [Medline].
Kon M, Sagi A. High-pressure water jet injury of the hand. J Hand Surg [Am]. May 1985;10(3):412-4. [Medline].
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Lewis HG, Clarke P, Kneafsey B, Brennen MD. A 10-year review of high-pressure injection injuries to the hand. J Hand Surg [Br]. Aug 1998;23(4):479-81. [Medline].
Loveday I. High-pressure injection injuries. Emerg Nurse. Nov 2007;15(7):22-3. [Medline].
Luber KT, Rehm JP, Freeland AE. High-pressure injection injuries of the hand. Orthopedics. Feb 2005;28(2):129-32. [Medline].
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Neal NC, Burke FD. High-pressure injection injuries. Injury. Nov 1991;22(6):467-70. [Medline].
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Keywords

hand injury, injection injury, high-pressure injection injury, grease gun injury, paint sprayer injury, diesel fuel injector injury, oleogranulomas, chronic fistula formation, chemical inflammation, finger amputation, fingertip injury, high pressure hand injury

Contributor Information and Disclosures

Author

Glen Vaughn, MD, Director, Department of Emergency Medicine, Defiance Hospital
Disclosure: Nothing to disclose.

Medical Editor

Dan Danzl, MD, Chair, Department of Emergency Medicine, Professor, University of Louisville Hospital
Dan Danzl, MD is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, American Medical Association, Kentucky Medical Association, Society for Academic Emergency Medicine, and Wilderness Medical Society
Disclosure: Nothing to disclose.

Pharmacy Editor

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

Managing Editor

Eric L Legome, MD, Chair, Department of Emergency Medicine, St Vincent's Hospital Manhattan; Associate Professor, Department of Emergency Medicine, New York Medical College
Eric L Legome, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Emergency Medicine, American College of Emergency Physicians, Council of Emergency Medicine Residency Directors, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

CME Editor

John D Halamka, MD, MS, Associate Professor of Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center; Chief Information Officer, CareGroup Healthcare System and Harvard Medical School; Attending Physician, Division of Emergency Medicine, Beth Israel Deaconess Medical Center
John D Halamka, MD, MS is a member of the following medical societies: American College of Emergency Physicians, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Chief Editor

Rick Kulkarni, MD, Assistant Professor of Surgery, Section of Emergency Medicine, Yale-New Haven Hospital
Rick Kulkarni, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Emergency Medicine, American College of Emergency Physicians, American Medical Association, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine
Disclosure: WebMD Salary Employment

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