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
- Clean water and air lower risk
- 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
- Distal finger
- Other finger/thumb
- Boutonniere deformity
- Mallet finger
- Jammed finger
- Jersey finger
- Trigger finger
- Ring avulsion injury
- De Quervain tenosynovitis
- Infiltrative tenosynovitis
- Metacarpophalangeal ulnar ligament rupture (Gamekeeper's thumb)
- Hand
- Wrist
- Drummer's wrist
- Ganglion cyst
- Lunotriquetral ligament instability
- Scaphoid fracture
- Extensor digitorum tenosynovitis
- Compressive neuropathy ("bracelet syndrome")
- Intersection syndrome
- Snapping Extensor Carpi Ulnaris
- Vaughn Jackson syndrome
- General
Evaluation
- Clinical diagnosis
- 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
- Increased rate of amputation if >10 hours to OR
- Tetanus
- Antibiotics
- Targeted at broad spectrum coverage. Traditionally a 3rd generation cephalosporin
- Analgesia
- Digital blocks are contraindicated as wound already under high pressure
Disposition
- Admit