High-Pressure Injection Injuries
Erez Avisar
High-pressure injection (HPI) injury has the potential to cause devastating injury to the limb. It has a high risk of being overlooked due to its often benign presentation. Failure to accurately diagnose this injury results in undertreatment and potentially devastating consequences. Patients usually present to the emergency room or to an outpatient setting soon after an injury occurs. Often, patients report an accidental or unexpected discharge of a high-pressure paint gun, after which they experienced a stinging sensation in the finger or hand followed by a disproportionate sensation of pain and swelling. Physicians can be misled by early objective physical findings, which may be limited to a minimal puncture wound. However, when recognized appropriately, early diagnosis and proper treatment can minimize the sequelae of injury including soft-tissue ischemia. The reported amputation rate of these injuries is between 30% and 48%.1
EPIDEMIOLOGY
It is estimated that annually 1 of 600 traumatic hand injuries involves an HPI injury.1,2 Commonly, young manual workers sustain injury to the upper limb, usually to the tip of the index finger. The most common scenario occurs while the worker is using his nondominant hand for testing or cleaning the tip of a paint gun.
PATHOPHYSIOLOGY
The type of material injected (gas, liquid, plastic paint, grease, paraffin, fuel, paint thinner) and the pressure of the instrument used have a substantial influence on the soft-tissue damage and the injury zone. A pressure of 100 psi is the minimum needed to penetrate the skin. Oil-based paint and turpentine are associated with the worst outcomes, whereas latex
paint is associated with more favorable outcomes.3 The primary insult to the digit is related to the volume and pressure of the material injected. Subsequent to the mechanical damage, the material’s inherent toxicity creates an inflammatory response that leads to edema and tissue ischemia. High-pressure air and water injections present with similar mechanisms of injury to material injections, but do not have the same inflammatory effect. Pain after these injuries is usually mild and disproportionate to the subcutaneous emphysema that rapidly spreads proximally. The prognosis is usually benign compared with material HPI injury from paint or oil.4
paint is associated with more favorable outcomes.3 The primary insult to the digit is related to the volume and pressure of the material injected. Subsequent to the mechanical damage, the material’s inherent toxicity creates an inflammatory response that leads to edema and tissue ischemia. High-pressure air and water injections present with similar mechanisms of injury to material injections, but do not have the same inflammatory effect. Pain after these injuries is usually mild and disproportionate to the subcutaneous emphysema that rapidly spreads proximally. The prognosis is usually benign compared with material HPI injury from paint or oil.4
The initial management of an HPI injury includes urgent hand surgery consultation. The patient should be sent for a toxoid vaccine in the case of radiopaque material or gas HPI injury. Radiographs can help in the estimation of the zone of injury (Figure 56.1).
Nonsurgical treatment may be considered in cases of air and water HPI injury, but patients should be admitted for close observation, and water injection in particular should be closely monitored for compartment syndrome.
Related posts:
Stay updated, free articles. Join our Telegram channel
Full access? Get Clinical Tree
