High-pressure injection injury

Background

• Surgical emergency
  • Amputation rates are as high as 30%
• Occurs with grease, paint, and fuel guns; usually injected into non-dominant hand
• Most important factor is type of injected material
  • Paint produces large, early inflammatory response with high rate of amputation
  • Grease causes small inflammatory response with lower rate of amputation

Clinical Features

• Most frequently in hand/fingers
• Benign appearance of small injection site in immediate post-injection period is misleading
  • With time digit becomes edematous, pale, and severely tender to palpation

Differential Diagnosis

Hand and finger injuries

• Radiograph positive
  • Hand and finger fractures
  • Hand and finger dislocations
  • Triquetrolunate ligament instability
• Radiograph negative
  • Dupeytren contracture
  • Boutonniere deformity
  • Hand and finger tendon injuries
  • Ganglion cyst
  • De Quervain tenosynovitis
  • Intersection syndrome
  • Drummer's wrist
  • Extensor digitorum tenosynovitis
  • Vaughn Jackson syndrome
  • Snapping Extensor Carpi Ulnaris
  • Compressive neuropathy, "bracelet syndrome"
  • Scaphoid fracture
  • Osteoarthritis
  • Infiltrative tenosynovitis
  • Gout
  • Rheumatoid arthritis
  • Trigger finger
  • Mallet finger
    • Swan neck deformity
  • Jersey finger
  • Jammed finger
  • Subungual hematoma
  • Fingertip laceration
  • Metacarpophalangeal (MCP) ulnar ligament rupture (Gamekeeper's thumb)
  • Nail avulsion
  • High-pressure injection injury

Evaluation

• Usually clinical
• Consider X-ray
  • May show extent of injection of radiopaque substances

Management

• Splint and Elevate
• Emergent ortho/hand surgeon consult
  • Early surgical decompression and debridement
  • >10hours to OR with increased amp rates
• Tetanus
• Antibiotics
• Analgesia
  • Digital blocks are contraindicated as wound already under high pressure

Disposition

• Admission

See Also

• Hand and finger injuries

References

Authors

Ross Donaldson