Medical Therapy
Following a thorough history, physical examination, and additional workup, tetanus prophylaxis, analgesia, and intravenous (IV) broad-spectrum antibiotic therapy should be administered. [27, 44]
In cases involving clean water and air injuries, good functional outcomes may be achieved with simple monitoring and conservative management. Such injuries should not be regarded as trivial, however. [45, 46]
Surgical Therapy
High-pressure injection (HPI) injuries are considered surgical emergencies. Surgical consultation should be obtained quickly. Pai et al suggested that the time interval from injury to treatment is a determinant of the eventual result. [14]
As with other hand injuries, the extremity should be elevated and splinted. With HPI injuries, ice should not be used as a treatment, because it promotes vasoconstriction and further exacerbates poor circulation. [27]
Grease, paint, and other chemical injuries
After the procedures mentioned above, wide surgical decompression with timely debridement of necrotic tissue and foreign material is essential. The patient should be under general anesthesia. Affected digits should be opened by using a Brunner incision or midlateral incision through their entire length. [5, 16] If material is adherent to the neurovascular bundles and cannot be removed, it should be left in place. [33] (See the images below.)
Photograph taken after urgent debridement following high-pressure injection injury involving paint.
Debridement of necrotic index and middle digits following treatment of high-pressure injection injury involving paint.
Intraoperatively, an Esmarch bandage should be avoided for hemostasis because the increased pressure spreads injected materials deeper into the subcutaneous tissues. The use of solvents other than isotonic sodium chloride solution for irrigation of a wound is not recommended. [41, 47] Furthermore, digital or local nerve blocks are contraindicated because they increase compartment pressures and are associated with poorer outcomes. [48]
Returning to the operating room for further irrigation and debridement is recommended, and the wound should be left open. [27] The use of negative-pressure wound therapy (NPWT) for these injuries has been described. [49, 50, 51]
Amputation rates range from 16% to 55% for HPI injuries. [18, 7, 13] Some physicians advocate amputation if the damage is severe and paint was injected into a digit. If a digit is initially cool or poorly perfused, consider early amputation. [7, 17, 52]
Because inflammation plays a key role in the extent of damage following HPI injuries, adjunctive use of steroids has been suggested for severe cases. Bottoms described using dexamethasone as an adjunct. [53] Since then, others have concurred with the use of high-dose systemic corticosteroids for HPI injuries, despite the theoretically increased risk of sepsis resulting from immunosuppression.
Lewis et al recommended that "steroids should be used with antibiotic coverage in all cases, with the exception of grease gun injuries with minimal tissue extension." They argued that the organic chemicals usually injected generally do not support bacterial growth. [7]
Clean water and air injuries
In contrast to HPI injuries with materials such as paint, grease, and other solvents, clean water and air injuries may result in good functional outcomes with simple monitoring and conservative management.
In a 1991 report, Peters suggested that, because of the clean and relatively nonirritating nature of the water supply in the city where the injuries were reported, aggressive surgical debridement was not warranted [19] ; however, if water from a polluted source is involved, immediate surgical exploration is warranted. HPI injuries with air have also been described as having a benign course. [21]
Postoperative Care
With all HPI injuries, physiotherapy in the early postinjury period is imperative for a good functional outcome. (See the image below.) Along with this treatment, swelling has been found to respond well to the application of custom-made intermittent-pressure garments. [36]
Excellent functional recovery after reconstruction of high-pressure injection injury with abdominal flap.
A retrospective study of HPI injury to the hand by Chaput et al suggested that performing a systematic "second look" 48-72 hours after initial debridement surgery may be useful in that it permits additional washing or debridement and gives the surgeon the option of performing a more conservative initial procedure. [54]
Long-Term Monitoring
Follow-up care should revolve around physical and occupational therapy, social work, and the psychosocial services team, in addition to close follow-up by the hand surgeon. Once maximum physical and occupational therapy and optimal splinting have been achieved by the patient, secondary surgical procedures should be considered. Capsulotomy, neurolysis, tenolysis, and soft-tissue reconstruction are all procedures that can be considered for restoring maximal function. [7]
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Photograph taken approximately 12 hours after high-pressure injection injury involving paint.
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Photograph taken after urgent debridement following high-pressure injection injury involving paint.
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Photograph taken 48 hours after high-pressure injection injury involving paint.
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Debridement of necrotic index and middle digits following treatment of high-pressure injection injury involving paint.
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Reconstruction of high-pressure injection injury with abdominal flap.
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Excellent functional recovery after reconstruction of high-pressure injection injury with abdominal flap.
