ED Management of High-Pressure Injection Injury

A 30-year-old right-hand-dominant man presents with complaints of pain and swelling at the distal phalangeal level of his left index finger. The symptoms began 5 hours ago shortly after he was injured while using a paint injection gun. He received a dose of cephalexin, ibuprofen, and tetanus prophylaxis. The radiograph of his hand is shown below. Is he ready for discharge? 

No.

High-pressure injection injury is a true surgical hand emergency. Diagnosis is often delayed, and patients are often discharged home due to the benign initial appearance of the injury which later results in amputation of the affected digit or hand (1-4). Morbidity is dependent to a large extent upon the type of material injected. Commonly injected materials are automotive grease, diesel oil, paint, and other solvents. 

Pathophysiology

Tissue damage may be either chemical or mechanical in nature. In general, the injected material creates a small open wound at the entrance point and then passes through the tissue and neurovascular structures until it faces resistance. This movement causes traumatic dissection, and pressure from the injected fluid can potentially cause compartment syndrome. The compartment pressure worsens with an increase in volume secondary to edema and inflammation. The injected material itself also further induces chemical damage. The clinical condition can rapidly deteriorate, and all of these factors can impair circulation, destroy tissue, and increase susceptibility to infection. For this last reason, broad-spectrum antibiotics are recommended.

Pain control

Preoperatively, consider local, regional or general anesthesia because the proximal extent of the injury cannot be known with certainty. Do NOT perform digital nerve blocks given the risk of increased compartement pressure at the fingers.

Antibiotic Choice

In Hogan and Ruland’s study (5), microbiological culture was positive with mixed bacteria in 42% of cases. Infection can develop even in patients who receive antibiotic therapy. However, their study did not show a statistically significant difference in amputation rates between culture-positive and culture-negative patients.

Steroids?

The administration of steroids in high-pressure injection injury dates back to 1962 when their anti-inflammatory effect was thought to help minimize inflammation and tissue damage. Recent literature, however, suggests that steroid use in this setting is controversial. Some authors advocate for steroid use in all patients, while others are concerned that steroid suppression of leukocyte response increases the risk of superinfection. Despite treating 15 patients with steroids, Hogan and Rutland noted that 8 of these patients still required amputation (5,6). 

Prognosis

The most significant prognostic factor in high-pressure gun injuries is time to diagnosis and notification of a hand surgeon. The rate of amputation has been shown to be lower in patients who receive debridement of necrotic tissues within the first 6 hours following injury (58% vs. 88%) (4).  The volume and properties of the injected material are also very important for prognosis, as injuries with organic solvents (thinner, gasoline, etc.) contribute to a higher risk of amputation than other materials (5).

Summary

High-pressure gun injuries are a true surgical emergency of the hand. As noted above, the most important prognostic factor is prompt, aggressive debridement by a hand surgeon within the first six hours following injury. 

References

1. Rees CE: Penetration of tissue by fuel oil under high pressure from diesel engine. J Am Med Assoc 1937;109:866-867.
2. 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;3(1):27-33.
3. Neal NC, Burke FD: High-pressure injection injuries. Injury 1991;22(6):467-470.
4. Amsdell SL, Hammert WC. High-Pressure Injection Injuries in the hand: current treatment concept. Plast Reconstr Surg 2013;132:e586-91.
5. Hogan CJ, Ruland RT: High-pressure injection injuries to the upper extremity: A review of the literature. J Orthop Trauma2006;20(7):503-511.
6. Mizani M, Weber B (2000) High-pressure injection injury of the hand. The potential for disastrous results. Postgrad Med 108(1):183–185–189–190 
7. Gutowski K, Chu J, Choi M, Friedman D (2003) High-pressure hand injection injuries caused by dry cleaning solvents: case reports, review of the literature, and treatment guidelines. Plast Reconstr Surg 111:174–177 
8. Kaufman HD: High pressure injection injuries, the problems, pathogenesis and management. Hand 1970;2(1):63-73.
9. Kaufman HD: The anatomy of experimentally produced high-pressure injection injuries of the hand. Br J Surg 1968;55(5):340-344.
10. Stark HH, Ashworth CR, Boyes JH: Paint-gun injuries of the hand. J Bone Joint Surg Am 1967;49(4):637-647.

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• ED Management of High-Pressure Injection Injury - August 9, 2019