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Emergency Medicine > TRAUMA AND ORTHOPEDICS
Hand Injury, High Pressure
Article Last Updated: Sep 7, 2006
AUTHOR AND EDITOR INFORMATION
Section 1 of 9  
Author: Glen Vaughn, MD, Director, Department of Emergency Medicine, Defiance Hospital
Editors: Dan Danzl, MD, Chair, Department of Emergency Medicine, Professor, University of Louisville Hospital; Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine; Eric Legome, MD, Residency Director, Assistant Professor of Emergency Medicine, Department of Emergency Medicine New York University, New York University Hospital, Bellevue Hospital Center, Manhattan VA; 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; Rick Kulkarni, MD, Medical Director, Assistant Professor of Surgery, Section of Emergency Medicine, Yale-New Haven Hospital
Author and Editor Disclosure
Synonyms and related keywords:
injection injury, high-pressure injection injury, grease gun injury, paint sprayer injury, diesel fuel injector injury, oleogranulomas, chronic fistula formation, chemical inflammation, amputation, fingertip injury, high pressure hand injury
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. For a photo demonstration of hydraulic injection injury, see Cornell Farmedic Training Program, Hydraulic Injection Injury.
Mortality/Morbidity
Overall incidence of amputation approaches 48%. 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.
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.
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.
- 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.
- 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.
Lab Studies
- Perform standard preoperative laboratory tests.
Imaging Studies
- Preoperative radiographs may facilitate the surgical strategy by localizing subcutaneous air, debris, or unanticipated fractures.
Emergency Department Care
- 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.
The goal of therapy is to prevent infections. Prophylactic broad-spectrum antibiotics are indicated.
Drug Category: Antibiotics
Therapy must cover all likely pathogens in the context of the clinical setting.
| Drug Name | Cefazolin (Ancef, Kefzol, Zolicef) |
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| Description | 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. |
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| Adult Dose | 1 g IV/IM q6-8h for 5-7 d |
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| Pediatric Dose | 25-50 mg/kg/d IV/IM divided tid/qid for 5-7 d |
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| Contraindications | Documented hypersensitivity |
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| Interactions | Probenecid prolongs effect; aminoglycosides may increase renal toxicity; may yield false-positive urine dip test for glucose |
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| Pregnancy | B - Usually safe but benefits must outweigh the risks.
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| Precautions | Adjust dose in renal impairment; superinfections and promotion of nonsusceptible organisms may occur with prolonged use or repeated therapy |
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| Drug Name | Trimethoprim/sulfamethoxazole (Bactrim, Bactrim DS) |
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| Description | 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. |
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| Adult Dose | 160 mg TMP or 800 mg SMZ PO q12h for 5-7 d |
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| Pediatric Dose | <2 months: Not recommended
Infants and children > 2 months: 15-20 mg/kg/d (TMP dose) PO divided tid/qid for 5-7 d |
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| Contraindications | Documented hypersensitivity; megaloblastic anemia due to folate deficiency
Do not administer to infants <2 mo |
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| 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 |
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| Pregnancy | C - Safety for use during pregnancy has not been established.
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| 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 |
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| Drug Name | Clindamycin (Cleocin) |
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| Description | 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. |
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| Adult Dose | 600-1200 mg/d IV/IM divided q6-8h for 5-7 d |
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| Pediatric Dose | 20-40 mg/kg/d IV/IM divided tid/qid |
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| Contraindications | Documented hypersensitivity; regional enteritis; ulcerative colitis; hepatic impairment; antibiotic-associated colitis |
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| Interactions | Increases duration of neuromuscular blockade induced by tubocurarine and pancuronium; erythromycin may antagonize effects; antidiarrheals may delay absorption |
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| Pregnancy | B - Usually safe but benefits must outweigh the risks.
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| Precautions | Adjust dose in severe hepatic dysfunction; no adjustment necessary in renal insufficiency; associated with severe and possibly fatal colitis |
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| Drug Name | Tetracycline (Sumycin) |
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| Description | 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. |
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| Adult Dose | 250-500 mg PO q6h |
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| Pediatric Dose | 25-50 mg/kg/d PO divided q6h |
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| Contraindications | Documented hypersensitivity; severe hepatic dysfunction |
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| 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 |
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| Pregnancy | D - Unsafe in pregnancy
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| 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 half of pregnancy through age 8 y) can cause permanent discoloration of teeth; Fanconilike syndrome may occur with outdated tetracyclines |
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| Drug Name | Amoxicillin (Amoxil, Biomox, Trimox) |
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| Description | Interferes with synthesis of cell wall mucopeptide during active multiplication, resulting in bactericidal activity against susceptible bacteria. |
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| Adult Dose | 250-500 mg PO q8h; not to exceed 3 g/d |
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| Pediatric Dose | 20-50 mg/kg/d PO divided q8h |
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| Contraindications | Documented hypersensitivity |
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| Interactions | Reduces efficacy of oral contraceptives |
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| Pregnancy | B - Usually safe but benefits must outweigh the risks.
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| Precautions | Adjust dose in renal impairment |
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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).
Further Outpatient Care
- Outpatient management 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.
Medical/Legal 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.
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- 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].
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Hand Injury, High Pressure excerpt Article Last Updated: Sep 7, 2006
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