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HIGH-PRESSURE INJECTION

INJURY OF THE FINGERS

Christian Dumontier MD, PhD
Centre de la Main, Guadeloupe

With the help of Dr Antonio DINH, Paris
1ST MCQ: WHICH STATEMENT
CONCERNING HIGH-PRESSURE INJECTION
INJURIES OF THE HAND IS FALSE?
1. They may be deceptively benign on initial presentation.
2. They carry a risk of infection.
3. They can be discharged on oral antibiotics with
outpatient hand surgery follow up.
4. They should be started on broad spectrum IV antibiotics.
5. They are surgical emergencies requiring timely operative
decompression and debridement.
From Welch J. High-pressure injection injury of the finger. Visual Journal of Emergency Medicine 10 (2018) 68–70
ANSWERS
• They can be discharged on oral antibiotics with outpatient hand surgery follow up.
Explanation: High-pressure injection injuries of the hand can be overlooked on initial
presentation due to the benign appearance of the entry wound. However these injuries
are surgical emergencies. An astute physician must have a high index of suspicion based
on the clinical history, even if the physical examination of the hand seems relatively
benign. Prognosis depends upon the location, pressure, type of material injected, and
the time to surgical debridement. Management includes IV antibiotics, tetanus
prophylaxis, and surgical decompression and debridement within 6 h of the injury.
Repeat surgical debridement at 48–72 h if often necessary for highly contaminated
wounds in order to remove all of the foreign material and necrotic tissue

• Comments: although IV antibiotics can be discussed as not all teams use it, otherwise I
agree with this MCQ
2ND MCQ: A 25 YR MALE PRESENTS 2 H AFTER A HIGH-PRESSURE
INJECTION INJURY TO HIS INDEX FINGER FROM A PAINT GUN
NOZZLE. HIS FINGER HAS A PUNCTURE SIGHT WITH SWELLING
DISTALLY. WHICH OF THE FOLLOWING IS A POTENTIAL
CONSEQUENCE OF THIS INJURY?

1. Tissue necrosis
2. Compartment syndrome
3. Functional loss of the involved part of the hand
4. Amputation
5. All of the above

From Welch J. High-pressure injection injury of the finger. Visual Journal of Emergency Medicine 10 (2018) 68–70
ANSWERS
• All of the above. Explanation: High-pressure injection injuries of the hand
typically results from wiping the top of a high-pressure nozzle with the
index finger. The foreign material is injected at high- pressures of 5000–
7000 psi into the finger and penetrates along the tendon sheaths and
facial planes causing tissue distention and local inflammatory response.
These injuries carry high risks of devastating consequences and can
cause tremendous damage including tissue necrosis, high compartment
pressures, compartment syndrome, ischemia, and thrombosis. Additional
complications and morbidity include infection, high rates of amputation
(range from 16% to 50%) chronic pain, stiffness, sensation loss, and loss
of function of the involved part of the hand
From Welch J. High-pressure injection injury of the finger. Visual Journal of Emergency Medicine 10 (2018) 68–70
TAKE HOME MESSAGE
• Rare injuries (1-4 cases per year in specialized centers
/ 1f 600 hand injuries in a emergency department)

• Huge contrast between apparently benign clinical
presentation and the high frequency of severe sequelae:
underestimation of the lesion +++

• A real emergency: « the emergency of emergencies
in hand surgery »
Schoo MJ, Scott FA, Boswick JA Jr. High-pressure injection injuries of the hand. J Trauma. 1980 Mar. 20(3):229-38
HISTORICAL

• Hesse, 1925

• Rees, 1937, diesel fuel injection

Hesse. Die chirurgische und gerichtichmedizinische bedeutung der kunstlich hervogerufenen
erkrankungen. Arch Klin Chir. 1925. 136:277-91
Rees CE. Penetration of tissue by fuel oil under high pressure from a diesel engine. JAMA. 1937.
109:866-7.
THE INJURY
• The patient was trying to clean
off the tip of a high-pressured
paint nozzle.

• He inadvertently presses the
trigger

• Male, average age 36 years, WRI

• Non-dominant hand 78%
(index finger in 50% of cases,
then thumb and middle 40%)
THE MACHINE
• Pressure can vary from 40 to 800
bar

• A pressure of 7 bar is sufficient to
penetrate the skin

• In a 1970 report, Kaufman compared
the kinetic energy from a grease gun
to a 1000-kg weight falling
from a height of 25 cm

• Injection over the membranous
portion of the sheath resulted with
filling of the sheath with the injected
material.

Kaufman HD. The anatomy of experimentally produced high-pressure injection injuries of the hand. Br J Surg. 1968 May. 55(5):340-4.
THE INJECTED FLUID
• Water, air, veterinary vaccine
cause little damage

• Grease, Diesel, Paints and solvents
have cytolytic properties

• Solvents have lower viscosity
➠ faster distribution along the
tissues

• Oil paints are more destructive
than water paints ➠ possible
general intoxication

Paint HP injury
CLINICAL PRESENTATION

• A small puncture mark on
the pulp

• Initially few or little pain or
symptoms (average time to
presentation is 9 hours)
CLINICAL PRESENTATION

• Swelling extend proximally
into the finger

• Decreased range of motion
(due to swelling or sheath
injection -may present like a
synovial sheath infection)

• Increased and severe pain

3 weeks after oil HPI
CLINICAL PRESENTATION

• Sometimes signes of
ischemia are present

• Diminished capillary refill

• Can appear late

Paint Injury
CLINICAL PRESENTATION

• Sometimes signes of neurologic injury are present

• Diminished sensibility

• Hypersensitivity
X-RAYS ARE MANDATORY
• You can see the extend of
the injury (air, paints,…)
From Welch J. High-pressure injection injury of the finger. Visual Journal of Emergency Medicine 10 (2018) 68–70
PROGNOSIS DEPENDS OF:
• The compression force

• Quality of injected material (water vs oil)

• Quantity (volume) of injected material

• Outpouring edema due to chemical irritation

• Site of injection (fingertip has a smaller expansion
capacity than the palm) ➠ x 3 amputation rate compare
to palm

• Delay before surgery: the only and maybe the most
important prognostic factor in the hands of
doctors
PATHOPHYSIOLOGY
• The injected fluid spreads along the neurovascular bundles ➠ traumatic
dissection, compression, vascular spasms ➠ tissue ischemia and thrombosis

• Tissue distension caused by the fluid itself or by swelling and edema can
cause a compartment syndrome

• Chemical damage by the fluid itself ➠ cytolysis causes tissue destruction,
necrosis and intense inflammatory response ➠ fibrosis of tissues with
strong restriction of hand function

• Secondary infection, favored by necrosis and ischemia ➠ large spectrum
antibiotics are (frequently) recommended. Corticosteroids have no effects.
AMPUTATION IS THE MOST
SEVERE CONSEQUENCE
• Rates of up to 30-48% have been
reported

• With solvents it goes up to 50-80%

• If patient presents with impaired
vascularity ➠ 100%

• If pressure < 70 bar ➠ 19%
amputation, > 70 bar ➠ 43%
amputation rate and if > 490 bar
➠ 100% amputation rate.
FROM HOGAN CJ. High-pressure injection injuries to the upper extremity. J ORTHOP TRAUMA 2006;20:504
https://emedicine.medscape.com/article/1241999-overview#a7
OTHER CONSEQUENCES
• Hyperesthesia (61%)

• Continuous pain (22%)

• Cold intolerance (78%)

• Contracture

• Reduces sensibility (35%)

• Stiffness

• Return to original work is rare
(44% same work)
WHAT TO DO IN EMERGENCY ?
• Try to get information on the composition of the product (possible
systemic intoxication) - control potential renal failures, intoxication with lead,
hemolysis,..

• Tetanus prophylaxis

• Systemic large spectrum antibiotics (can be discussed but very frequently
recommended)

• Call a hand surgeon and prepare patient for the OR

• Steroids has been suggested for severe cases but it does not change the rate
of amputation nor increase the risk of infection
SURGICAL TREATMENT = EMERGENCY
• Plexus block (for vasodilatation) or general
anesthesia - not local (increase pressure)

• Tourniquet (elevation, no Esmach bandage
that spreads the material)

• Removal of all foreign material +++ most
often lavage cannot remove insoluble
materials -Incomplete debridement may
lead to ganulomas, oleogranulomas,
fibrohistiocytic tumors,…

• Lavage with saline (not with solvent -
toxicity)

• Control vascularisation (no Ice)
Surgery performed late (3 weeks)
Saraf S. High-pressure injection injury of the finger. Ind J. Ortho 2012;46(6):725-727.
SURGICAL TREATMENT
• Arteriolysis

• Neurolysis

• Controle sheath injection

• Leave open the incisions - Second look is frequently needed.

• Immediate amputation can be discussed in case of a severe
ischemia
POSTOPERATIVE TREATMENT

• Put patient on splint (intrinsic Plus position)

• Early and prolonged rehabilitation (start at Day
2-3)
OUTCOMES

• ROM deficit average 8° at
the MP, 24° at the PIP and
30° at the DIP

• Average loss of strength
20%

• Only 8% had normal
sensation
IS THERE A PLACE FOR A NON-SURGICAL
TREATMENT ?
YES, BUT VERY LIMITED

• Low pressure injuries,

• Water or air injuries,

• Antibiotics, tetanus prophylaxis,

• Observation of the neurovascular situation of
fingers
PREVENTION
i n g
t k
a e
o r
f ha r g
h m c
r it t in
gl o tien
A pa
SOME REFERENCES
• N. Verhoeven, R. Hierner. High-pressure injection injury of the
hand: an often underestimated trauma: case report with study
of the literature. Strat Traum Limb Recon (2008) 3:27–33.

• JS Arneja. High-Pressure Injection Injuries. https://
emedicine.medscape.com/article/1241999-overview

• TA. Cannon. High-pressure Injection Injuries of the Hand.
Orthop Clin N Am 47 (2016) 617–624