Reminder of important clinical lesson
CASE REPORT
Digital high-pressure injection injury: the importance of early recognition and treatment Umran Sarwar, Muhammad Javed, Shakeel Rahman, Thomas C Wright Welsh Centre for Burns and Plastic Surgery, Swansea, UK Correspondence to Umran Sarwar, [email protected] Accepted 17 January 2014
SUMMARY High-pressure injection (HPI) injuries are an uncommon mechanism of trauma. The clinical effects of the HPI injury depend upon a number of variables including the pressures involved, chemical toxicity, quantity of material injected and its temperature. Evidence within the literature has shown that delay in identifying and treating such injuries can lead to devastating consequences. We describe one such case of a HPI injury involving engine oil to a digit. In addition, we review the clinical course, pathophysiology and management of such injuries.
BACKGROUND High-pressure injection (HPI) injuries to the digit usually present as small benign wounds, which often mask the severe underlying trauma to the tissues. These injuries require early recognition and prompt review by senior surgical teams as they represent surgical emergencies. All emergency department staff and hand surgeons should be aware of this serious injury to minimise potential morbidity.
To cite: Sarwar U, Javed M, Rahman S, et al. BMJ Case Rep Published online: [please include Day Month Year] doi:10.1136/bcr-2013203206
Figure 1 Lateral radiograph demonstrating the lucency within the volar soft tissues of the digit.
Sarwar U, et al. BMJ Case Rep 2014. doi:10.1136/bcr-2013-203206
CASE PRESENTATION A 49-year-old, otherwise fit-and-well male, presented to a local emergency department 2 h after an injury to his non-dominant left index finger as a result of malfunction of a pressurised pipe containing engine oil. Initial examination identified a 3 mm puncture wound to the radial aspect of his middle phalanx with only minor swelling. A plain radiograph was initially reported as normal (figure 1). A plan for discharge with antibiotics, with a review of the digit in 48 h was made. An hour later, a further review was requested as the patient was experiencing intense pain over the finger with increased swelling. On further examination, swelling now extended proximally to involve the metacarpophalangeal joint. The patient was referred to the plastic surgery department for further review. On review by a junior trainee, the patient exhibited no change in clinical findings with full range of movement and no neurovascular compromise. The patient was admitted for observation, but no senior review was arranged. On the consultant’s morning ward-round, the finger showed marked swelling with blistering and poor capillary refill (figures 2 and 3). The patient was taken to the theatre for urgent debridement. The puncture wound was excised, extended and explored via mid-lateral incisions, joined over the
Figure 2 Day 1 post injury. Note the small puncture wound over the middle phalanx. 1
Reminder of important clinical lesson DISCUSSION
Figure 3 Day 1 post injury. Note the extensive blistering along the digit. joint creases, to fully decompress the finger. Unfortunately, the soft tissues were poorly perfused with oil extending proximally to the distal palmar crease. The wound was irrigated and the carpal tunnel decompressed. Intravenous antibiotics, splintage and elevation of the hand were continued and the patient underwent serial debridement of necrotic tissue over the next 4 days (figure 4). He finally required terminalisation at the level of the mid-proximal phalanx. The patient was then discharged with hand therapy clinic follow-up.
INVESTIGATIONS Radiographs of the hand and digit.
TREATMENT
HPI injuries have an incidence of 1 in 600 hand trauma cases and are predominantly occupational injuries, usually occurring in men.1 Commonly the index or middle fingers of the nondominant hand are involved.2–4 Numerous materials have been implicated in the aetiology including grease, paint, diesel, air, water, molten metal and wax, all injected under high pressures sometimes reaching as high as 10 000 psi.5–9 Following HPI injury, swelling, numbness and even vascular insufficiency can ensue. This is due to a combination of direct mechanical and chemical trauma.10 The clinical effects of the HPI injury are dependent on the pressures involved, chemical toxicity, quantity and temperature of the material injected and tamponade effect due to subsequent oedema.11–15 Chemicals may cause tissue necrosis and intense inflammatory responses, which can lead to fibrosis, resulting in restriction of hand function.11 13 16–18 The injury can be further complicated by infection introduced primarily during the injection or developing secondarily. Ischaemia and necrosis further exacerbate this secondary infection.17 19 Clinically, the injury presents with a benign appearing wound, as demonstrated in our case, which can often mislead the examining physician and cause a delay in the appropriate treatment.20 21 A history of injection of any material under high pressure should prompt the emergency or primary healthcare professional to seek urgent expert surgical opinion. A detailed history of the mechanism should be taken focusing on the time of the injury, volume, nature of material and an estimate of ejection pressure.10 Initial radiographs may display particulate matter as well as airtracks within the soft tissues. Intravenous antibiotics should be started, tetanus prophylaxis should be administered where required and prompt surgical exploration and decompression performed as any time-delay between the injury and subsequent treatment can have a critical impact on the final outcome.20 22 Hogan et al’s20 review showed low amputation rates following injections of organic solvents when they underwent debridement within 6 h of injury compared to cases where surgery was delayed for more than 6 hours. When toxic substances such as paint, diesel, oil, paint thinner and gasoline were involved, the time to debridement had a significant impact upon survival of the body part and in cases where debridement was delayed more than 1 week the amputation risk rose to 88%.20 HPI injuries can result in restricted motion and loss of strength.21 23–32 One study demonstrated a 19% reduction in grip strength and a 25% reduction in 3-point pinch strength after this injury.23 In summary, HPI injuries to the digit usually present as a small benign wound which often masks the severe underlying trauma. These injuries require early recognition and prompt surgical treatment by experienced surgeons. All emergencydepartment staff and hand surgeons should be aware of this serious injury to minimise potential morbidity.
Surgical debridement and terminalisation of the digit.
Learning points
Figure 4 Intraoperative findings prior to terminalisation of the digit. 2
▸ A good history and examination is essential in all hand trauma. ▸ Innocuous-looking wounds can hide extensive deeper tissue damage. ▸ High-pressure injection injuries should always be discussed with a specialist hand unit. ▸ Timely intervention can improve morbidity. ▸ Review patients repeatedly as an initial trivial injury can progress rapidly to digit/limb loss. Sarwar U, et al. BMJ Case Rep 2014. doi:10.1136/bcr-2013-203206
Reminder of important clinical lesson Contributors US, MJ, SR and TCW contributed to the design, data collection, write-up and review of the final article. Competing interests None.
16
17
Patient consent Obtained. Provenance and peer review Not commissioned; externally peer reviewed.
REFERENCES 1 2 3 4 5 6 7 8
9 10 11 12 13 14 15
Rees CE. Penetration of tissue by fuel oil under high pressure from a diesel engine. JAMA 1937;109:866–7. Gillespie CA, Rodeheaver GT, Smith S, et al. Airless paint gun injuries: definition and management. Am J Surg 1974;128:383–91. Kaufman HD. The clinicopathological correlation of high-pressure injection injuries. Br J Surg 1968;55:214–18. Ramos H, Posch JL, Lie KM. High -pressure injection injuries of the hand. Plast Reconstr Surg 1970;45:221–6. Schoo MJ, Scott FA, Boswick JA Jr. High-pressure injection injuries of the hand. J Trauma 1980;20:229–38. Peters W. High-pressure injection injuries. Can J Surg 1991;34:511–13. Bandyopadhyay C, Mitra A, Harrison RJ. Ocular injury with high-pressure paint: a case report. Arch Environ Occup Health 2009;64:135–6. Gutowski KA, Chu J, Choi M, et al. High-pressure hand injection injuries caused by dry cleaning solvents: case reports, review of the literature, and treatment guidelines. Plast Reconstr Surg 2003;111:174–7. Loveday I. High-pressure injection injuries. Emerg Nurse 2007;15:22–3. Smith GD. High pressure injection injuries. Trauma 2005;7:95. Lewis RC Jr. High-compression injection injuries to the hand. Emerg Med Clin North Am 1985;3:373–81. Kaufman HD. High pressure injection injuries, the problems, pathogenesis and management. Hand 1970;2:63–73. Lewis HG, Clarke P, Kneafsey B, et al. A 10-year review of high-pressure injection injuries to the hand. J Hand Surg [Br] 1998;23:479–81. Dickson RA. High pressure injection injuries of the hand. A clinical, chemical and histological study. Hand 1976;8:189–93. Craig EV. A new high-pressure injection injury of the hand. J Hand Surg [Am] 1984;9:240–2.
18 19
20 21 22 23 24 25 26 27
28 29 30
31 32
Verhoeven N, Hierner R. High-pressure injection injury of the hand: an often underestimated trauma: case report with study of the literature. Strateg Trauma Limb Reconstr 2008;3:27–33. Moutet F, Chaussard C, Guinard D, et al. Injections a ‘haute pression au niveau de la main. Monographie de la societe’ francaise de chirurgie de la main no. 25, Infections de la main. 1998:83–91. Wieder A, Lapid O, Plakht Y, et al. A long term follow-up of high-pressure injection injuries to the hand. Plast Reconstr Surg 2006;117:186–9. 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;43:539–42. Hogan CJ, Ruland RT. High-pressure injection injuries to the upper extremity: a review of the literature. J Orthop Trauma 2006;20:503–11. Neal NC, Burke FD. High-pressure injection injuries. Injury 1991;22:467–70. Stark HH, Ashworth CR, Boyes JH. Paint-gun injuries of the hand. J Bone and Joint Surg 1967;49:637–47. Christodoulou L, Melikyan EY, Woodbridge S, et al. Functional outcome of high pressure injection injuries of the hand. J Trauma 2001;50:717–20. Geller ER, Gursel E. A unique case of high pressure injection injury of the hand. J Trauma 1986;26:483–5. Markal N, Celebioglu S. Compression neuropathy of the hand after high pressure air injection. Ann Plast Surg 2000;44:680–1. Maxwell RJ, Dixon PL. High pressure injection injuries of the hand: a report of three cases. Aust NZ J Surg 1988;58:344–6. O’Sullivan ST, Beausang E, O’Donoghue JM. The importance of open wound management in high pressure injection injuries of the upper limb. J Hand Surg B 1997;22B:542–3. Benson EA. Grease gun injury. Br J Surg 1969;56:397–9. Blue AI, Dirstine MJ. Grease gun damage, subcutaneous injection of paint, grease and other materials by pressure guns. Northwest Med 1965;64:342–4. Bottoms RWA. A case of high pressure hydraulic tool injury to the hand, its treatment aided by dexamethasone and a plea for a further trial of this substance. Med J Aust 1962;2:591–2. Couzens G, Burke FD. Veterinary high pressure injections with inoculations for larger animals. J Hand Surg B 1995;20B:497–9. Dial DE. Hand injuries due to injection of oil at high pressures. JAMA 1938;110:1747.
Copyright 2014 BMJ Publishing Group. All rights reserved. For permission to reuse any of this content visit http://group.bmj.com/group/rights-licensing/permissions. BMJ Case Report Fellows may re-use this article for personal use and teaching without any further permission. Become a Fellow of BMJ Case Reports today and you can: ▸ Submit as many cases as you like ▸ Enjoy fast sympathetic peer review and rapid publication of accepted articles ▸ Access all the published articles ▸ Re-use any of the published material for personal use and teaching without further permission For information on Institutional Fellowships contact [email protected] Visit casereports.bmj.com for more articles like this and to become a Fellow
Sarwar U, et al. BMJ Case Rep 2014. doi:10.1136/bcr-2013-203206
3
CASE REPORT
Digital high-pressure injection injury: the importance of early recognition and treatment Umran Sarwar, Muhammad Javed, Shakeel Rahman, Thomas C Wright Welsh Centre for Burns and Plastic Surgery, Swansea, UK Correspondence to Umran Sarwar, [email protected] Accepted 17 January 2014
SUMMARY High-pressure injection (HPI) injuries are an uncommon mechanism of trauma. The clinical effects of the HPI injury depend upon a number of variables including the pressures involved, chemical toxicity, quantity of material injected and its temperature. Evidence within the literature has shown that delay in identifying and treating such injuries can lead to devastating consequences. We describe one such case of a HPI injury involving engine oil to a digit. In addition, we review the clinical course, pathophysiology and management of such injuries.
BACKGROUND High-pressure injection (HPI) injuries to the digit usually present as small benign wounds, which often mask the severe underlying trauma to the tissues. These injuries require early recognition and prompt review by senior surgical teams as they represent surgical emergencies. All emergency department staff and hand surgeons should be aware of this serious injury to minimise potential morbidity.
To cite: Sarwar U, Javed M, Rahman S, et al. BMJ Case Rep Published online: [please include Day Month Year] doi:10.1136/bcr-2013203206
Figure 1 Lateral radiograph demonstrating the lucency within the volar soft tissues of the digit.
Sarwar U, et al. BMJ Case Rep 2014. doi:10.1136/bcr-2013-203206
CASE PRESENTATION A 49-year-old, otherwise fit-and-well male, presented to a local emergency department 2 h after an injury to his non-dominant left index finger as a result of malfunction of a pressurised pipe containing engine oil. Initial examination identified a 3 mm puncture wound to the radial aspect of his middle phalanx with only minor swelling. A plain radiograph was initially reported as normal (figure 1). A plan for discharge with antibiotics, with a review of the digit in 48 h was made. An hour later, a further review was requested as the patient was experiencing intense pain over the finger with increased swelling. On further examination, swelling now extended proximally to involve the metacarpophalangeal joint. The patient was referred to the plastic surgery department for further review. On review by a junior trainee, the patient exhibited no change in clinical findings with full range of movement and no neurovascular compromise. The patient was admitted for observation, but no senior review was arranged. On the consultant’s morning ward-round, the finger showed marked swelling with blistering and poor capillary refill (figures 2 and 3). The patient was taken to the theatre for urgent debridement. The puncture wound was excised, extended and explored via mid-lateral incisions, joined over the
Figure 2 Day 1 post injury. Note the small puncture wound over the middle phalanx. 1
Reminder of important clinical lesson DISCUSSION
Figure 3 Day 1 post injury. Note the extensive blistering along the digit. joint creases, to fully decompress the finger. Unfortunately, the soft tissues were poorly perfused with oil extending proximally to the distal palmar crease. The wound was irrigated and the carpal tunnel decompressed. Intravenous antibiotics, splintage and elevation of the hand were continued and the patient underwent serial debridement of necrotic tissue over the next 4 days (figure 4). He finally required terminalisation at the level of the mid-proximal phalanx. The patient was then discharged with hand therapy clinic follow-up.
INVESTIGATIONS Radiographs of the hand and digit.
TREATMENT
HPI injuries have an incidence of 1 in 600 hand trauma cases and are predominantly occupational injuries, usually occurring in men.1 Commonly the index or middle fingers of the nondominant hand are involved.2–4 Numerous materials have been implicated in the aetiology including grease, paint, diesel, air, water, molten metal and wax, all injected under high pressures sometimes reaching as high as 10 000 psi.5–9 Following HPI injury, swelling, numbness and even vascular insufficiency can ensue. This is due to a combination of direct mechanical and chemical trauma.10 The clinical effects of the HPI injury are dependent on the pressures involved, chemical toxicity, quantity and temperature of the material injected and tamponade effect due to subsequent oedema.11–15 Chemicals may cause tissue necrosis and intense inflammatory responses, which can lead to fibrosis, resulting in restriction of hand function.11 13 16–18 The injury can be further complicated by infection introduced primarily during the injection or developing secondarily. Ischaemia and necrosis further exacerbate this secondary infection.17 19 Clinically, the injury presents with a benign appearing wound, as demonstrated in our case, which can often mislead the examining physician and cause a delay in the appropriate treatment.20 21 A history of injection of any material under high pressure should prompt the emergency or primary healthcare professional to seek urgent expert surgical opinion. A detailed history of the mechanism should be taken focusing on the time of the injury, volume, nature of material and an estimate of ejection pressure.10 Initial radiographs may display particulate matter as well as airtracks within the soft tissues. Intravenous antibiotics should be started, tetanus prophylaxis should be administered where required and prompt surgical exploration and decompression performed as any time-delay between the injury and subsequent treatment can have a critical impact on the final outcome.20 22 Hogan et al’s20 review showed low amputation rates following injections of organic solvents when they underwent debridement within 6 h of injury compared to cases where surgery was delayed for more than 6 hours. When toxic substances such as paint, diesel, oil, paint thinner and gasoline were involved, the time to debridement had a significant impact upon survival of the body part and in cases where debridement was delayed more than 1 week the amputation risk rose to 88%.20 HPI injuries can result in restricted motion and loss of strength.21 23–32 One study demonstrated a 19% reduction in grip strength and a 25% reduction in 3-point pinch strength after this injury.23 In summary, HPI injuries to the digit usually present as a small benign wound which often masks the severe underlying trauma. These injuries require early recognition and prompt surgical treatment by experienced surgeons. All emergencydepartment staff and hand surgeons should be aware of this serious injury to minimise potential morbidity.
Surgical debridement and terminalisation of the digit.
Learning points
Figure 4 Intraoperative findings prior to terminalisation of the digit. 2
▸ A good history and examination is essential in all hand trauma. ▸ Innocuous-looking wounds can hide extensive deeper tissue damage. ▸ High-pressure injection injuries should always be discussed with a specialist hand unit. ▸ Timely intervention can improve morbidity. ▸ Review patients repeatedly as an initial trivial injury can progress rapidly to digit/limb loss. Sarwar U, et al. BMJ Case Rep 2014. doi:10.1136/bcr-2013-203206
Reminder of important clinical lesson Contributors US, MJ, SR and TCW contributed to the design, data collection, write-up and review of the final article. Competing interests None.
16
17
Patient consent Obtained. Provenance and peer review Not commissioned; externally peer reviewed.
REFERENCES 1 2 3 4 5 6 7 8
9 10 11 12 13 14 15
Rees CE. Penetration of tissue by fuel oil under high pressure from a diesel engine. JAMA 1937;109:866–7. Gillespie CA, Rodeheaver GT, Smith S, et al. Airless paint gun injuries: definition and management. Am J Surg 1974;128:383–91. Kaufman HD. The clinicopathological correlation of high-pressure injection injuries. Br J Surg 1968;55:214–18. Ramos H, Posch JL, Lie KM. High -pressure injection injuries of the hand. Plast Reconstr Surg 1970;45:221–6. Schoo MJ, Scott FA, Boswick JA Jr. High-pressure injection injuries of the hand. J Trauma 1980;20:229–38. Peters W. High-pressure injection injuries. Can J Surg 1991;34:511–13. Bandyopadhyay C, Mitra A, Harrison RJ. Ocular injury with high-pressure paint: a case report. Arch Environ Occup Health 2009;64:135–6. Gutowski KA, Chu J, Choi M, et al. High-pressure hand injection injuries caused by dry cleaning solvents: case reports, review of the literature, and treatment guidelines. Plast Reconstr Surg 2003;111:174–7. Loveday I. High-pressure injection injuries. Emerg Nurse 2007;15:22–3. Smith GD. High pressure injection injuries. Trauma 2005;7:95. Lewis RC Jr. High-compression injection injuries to the hand. Emerg Med Clin North Am 1985;3:373–81. Kaufman HD. High pressure injection injuries, the problems, pathogenesis and management. Hand 1970;2:63–73. Lewis HG, Clarke P, Kneafsey B, et al. A 10-year review of high-pressure injection injuries to the hand. J Hand Surg [Br] 1998;23:479–81. Dickson RA. High pressure injection injuries of the hand. A clinical, chemical and histological study. Hand 1976;8:189–93. Craig EV. A new high-pressure injection injury of the hand. J Hand Surg [Am] 1984;9:240–2.
18 19
20 21 22 23 24 25 26 27
28 29 30
31 32
Verhoeven N, Hierner R. High-pressure injection injury of the hand: an often underestimated trauma: case report with study of the literature. Strateg Trauma Limb Reconstr 2008;3:27–33. Moutet F, Chaussard C, Guinard D, et al. Injections a ‘haute pression au niveau de la main. Monographie de la societe’ francaise de chirurgie de la main no. 25, Infections de la main. 1998:83–91. Wieder A, Lapid O, Plakht Y, et al. A long term follow-up of high-pressure injection injuries to the hand. Plast Reconstr Surg 2006;117:186–9. 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;43:539–42. Hogan CJ, Ruland RT. High-pressure injection injuries to the upper extremity: a review of the literature. J Orthop Trauma 2006;20:503–11. Neal NC, Burke FD. High-pressure injection injuries. Injury 1991;22:467–70. Stark HH, Ashworth CR, Boyes JH. Paint-gun injuries of the hand. J Bone and Joint Surg 1967;49:637–47. Christodoulou L, Melikyan EY, Woodbridge S, et al. Functional outcome of high pressure injection injuries of the hand. J Trauma 2001;50:717–20. Geller ER, Gursel E. A unique case of high pressure injection injury of the hand. J Trauma 1986;26:483–5. Markal N, Celebioglu S. Compression neuropathy of the hand after high pressure air injection. Ann Plast Surg 2000;44:680–1. Maxwell RJ, Dixon PL. High pressure injection injuries of the hand: a report of three cases. Aust NZ J Surg 1988;58:344–6. O’Sullivan ST, Beausang E, O’Donoghue JM. The importance of open wound management in high pressure injection injuries of the upper limb. J Hand Surg B 1997;22B:542–3. Benson EA. Grease gun injury. Br J Surg 1969;56:397–9. Blue AI, Dirstine MJ. Grease gun damage, subcutaneous injection of paint, grease and other materials by pressure guns. Northwest Med 1965;64:342–4. Bottoms RWA. A case of high pressure hydraulic tool injury to the hand, its treatment aided by dexamethasone and a plea for a further trial of this substance. Med J Aust 1962;2:591–2. Couzens G, Burke FD. Veterinary high pressure injections with inoculations for larger animals. J Hand Surg B 1995;20B:497–9. Dial DE. Hand injuries due to injection of oil at high pressures. JAMA 1938;110:1747.
Copyright 2014 BMJ Publishing Group. All rights reserved. For permission to reuse any of this content visit http://group.bmj.com/group/rights-licensing/permissions. BMJ Case Report Fellows may re-use this article for personal use and teaching without any further permission. Become a Fellow of BMJ Case Reports today and you can: ▸ Submit as many cases as you like ▸ Enjoy fast sympathetic peer review and rapid publication of accepted articles ▸ Access all the published articles ▸ Re-use any of the published material for personal use and teaching without further permission For information on Institutional Fellowships contact [email protected] Visit casereports.bmj.com for more articles like this and to become a Fellow
Sarwar U, et al. BMJ Case Rep 2014. doi:10.1136/bcr-2013-203206
3
