High pressure injection injuries Dr Sean Nicklin
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High pressure injection injuries to the hand are surgical emergencies that require timely treatment to prevent infection, necrosis, and potential amputation. While such injuries are rare occurrences, the initial injury can dissect tissue along planes of least resistance, damaging neurovascular bundles. Local chemical irritation from substances like paint or grease also induce a severe inflammatory response. Without early thorough debridement within 6 hours, the injected material and damaged tissue promote secondary infection that can spread proximally. Even with treatment, outcomes depend on several factors like the pressure and chemicals involved as well as the location, with injuries to the fingers having poorer prognoses than the palm.
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High pressure injection injuries Dr Sean Nicklin
- 1. High pressure injection injuries Sean Nicklin Hand Surgeon Sydney Hospital, Prince of Wales & Sydney Children's Hospitals
- 2. High pressure injection injuries • High pressure injection into hand • Paint, paint stripper, grease, oil, water, air • First cases described by Hesse in 1925 (German) • Rees 1937 • Jet fuel R MF 4000psi • Infection and necrosis • Surgical emergency • Timely I&D, debridement and washout • Severity of injury often underestimated
- 3. Epidemiology • 1 in 600 hand traumas • 1-4 / year large centres • Patient: • Male • 35 yo • Labourer • Industrial cleaning, fueling, painting • Site: • Non dominant hand • Index finger (>50%) > palm > rest of hand • Mechanism: • Cleaning nozzle with hand or cloth • Grasping pressurised tubing with leak
- 4. Pathophysiology •Important factors • Initial injury • Local chemical irritation • Superimposed infection
- 5. Initial Injury • Pressures: 3000 to 10,000 psi • 100 psi sufficient to penetrate skin - only with direct contact • Grease gun injury • Equivalent to 1000 kg from 25 cm • Dissection along planes of least resistance • Commonly neurovascular bundles • Ischaemia • Vascular injury • Oedema • Volume
- 6. Factors – rare occurrence • High pressure fluids common in industry, but HPI relatively rare • 3 factors • Dimensions of jet • Pressure of jet • Proximity to skin • All need to be right (wrong) • HPI rare, but high pressure fluids common in industry • Near misses – thousands for every actual HPI injury • Decreasing
- 7. Initial Injury • Site important in deep injury • High pressure = less predictable • Fingers • Deflect from robust tissues e.g. Annular pulleys • Penetrate soft tissues e.g. flexor sheath at cruciate pulleys • Up to 750 psi in anatomical studies • LF ulnar bursa • Thumb radial bursa • Communicate in 80% patients • Higher pressures • Thumb and IF thenar space • MF to LF mid-palmer space
- 8. Initial Injury • Mid palm • Deposition of material deep to palmar aponeurosis • Occasional through and through injuries
- 9. Local chemical irritation • Common: • Paint, grease, hydraulic fluid, diesel, paint thinner • Features: • Intrinsically cytotoxic • Induce large inflammatory response • Dissolve fats/nerve sheaths e.g. turpentine • Viscosity can determine extent of injury • Prognosis: • Oil based paints - 58% amputation • Grease – 6% amputation • Air or water – rare amputation Poorer prognosis Better prognosis Paint (oil based) Grease Water Air Water based paint
- 10. Secondary infection • Superimposed infection • Necrotic material • Polymicrobial • Can propagate proximally along dissected tissue planes • Sepsis
- 11. Natural history • Clinical stages (Mason and Queen, 1941) • Acute • Immediate • Spasm, compression, damage to neurovascular bundles • Ischaemia • Intermediate • Foreign body reaction • Severe fibrosis • Formation of granulomas • Stiffness and loss of function • Late • Remodeling phase • Breakdown of granulomas • Widespread cutaneous lesions and sinuses • Malignancies reported
- 12. Clinical presentation • Symptoms • Early • Initially pain-free • Delay presentation • Late • Progressive pain and parasthaesia • Signs • Early • Small punctate lesion over grasping surface • Injectate expressed • Innocuous appearance • Late • Swelling • Neurovascular compromise • Flexor tenosynovitis • Necrotising fasciitis • Acute carpal tunnel syndrome
- 13. Initial management • At site • Awareness • Act swiftly • Clean site – area of pain • Transit • Emergency – ensure emergency services aware of injury • Bypass smaller hospitals if possible – hand unit • Emergency department
- 14. Initial management • Investigations • XR • FB • Radio-opaque chemical • Underlying bone injury • Bloods • Elevate limb • Tetanus prophylaxis • IV antibiotics • Analgesia • Resting splint • Monitor for compartment syndrome
- 15. Surgical management • Conservative: • Air • Water (unless requires surgical decompression) • Chicken vaccine • Others: • Early and thorough debridement • < 6 hours
- 16. Surgical management • Wide debridement of involved tissue • Fingers – non pinch, non protective surfaces • Mid palm incision for mid palm space • Decompression of tissue compartments • +/- carpal tunnel, Guyons canal, forearm if required • Exploration of tendon sheaths (preserve A2, A4) • Removal of injected material • Washout • Loose wound closure • Coverage of gliding tissues and neurovascular elements • Keep gliding tissues moist
- 17. Surgical management • Repeat debridement at 24-72 hours may be required • Multiple debridement's may be required • Once adequate wound bed established, soft tissue coverage with skin graft / flap may be necessary • Early active, active assisted and pROM stressing tendon gliding and digital oedema control
- 18. Steroids and antibiotics • Steroids • Controversial • Minimise swelling / inflammatory response • ?impact on superimposed infection • Antibiotics • Cover both gram positive and gram negative
- 19. Rehabilitiation • Hand therapist • Not always readily available – worth effort • Tissue injured • Tendons, joints, skin, nerves • Site of injury • Volar v dorsal • Time to healing • Prolonged open wounds or skin grafts • Improvement over one year • Significant change over 3 months
- 20. Outcomes • Stiffness • Amputation • Higher pressures (>1000 psi) • Chemicals (e.g. paint vs water) • Location (fingers > palm) • Time to surgery • > 6 hours, higher rates of amputation • Hogan et al 2006, meta analysis Schoo et al, 1980 (127 cases) Rates of amputation Paint thinner 80% (oil based) Paint 58% Automotive grease 23% Hydraulic fluid 14% Air or water rare
- 25. Summary • HPI injury rare • Near misses are not • Emergency • Time of presentation critical • Poor outcomes • Early treatment • Hand units • High index of suspicion
- 26. References • 1. Rosenwasser M, Wei D. High-pressure Injection Injuries to the Hand. Journal of the American Academy of Orthopaedic Surgeons. 2014;22(1):38-45. doi:10.5435/jaaos- 22-01-38 • 2. Luber K, Rehm J, Freekand A. High-Pressure Injection Injuries of the Hand. Orthopedics. 2005;28(2):129-132. • 3. Hogan C, Ruland R. High-pressure Injection Injuries to the Upper Extremity: A Review of the Literature. J Orthop Trauma. 2006;20(7):503-511. doi:10.1097/00005131-200608000-00010 • 4. Schoo M, Scott F, Boswick J. High-pressure injection injuries of the hand. Journal of Trauma. 1980;20(3).