Tuesday, April 14, 2015

Intense Pain Following High-pressure Injection Injury

Intense Pain Following High-pressure Injection Injury


Case presentation: A 30-year-old automobile technician presents to the emergency department with a complaint  of pain and swelling in the dorsum of his left hand near the metacarpophalangeal (MCP) joint of his index finger after injury with a grease injector. 

On examination, there is slight swelling of the dorsum of the hand and a small pinpoint puncture wound just proximal to the MCP joint of the index finger as noted in the picture. There is pain with passive movement and good capillary refill of
the index finger and thumb, and no neurologic deficits distal to the injury are appreciated.
Question: 

What is the most appropriate management?
A. Check tetanus status, prescribe analgesics, and discharge home
B. Prescribe antibiotics and analgesics, check tetanus status, and discharge home
C. Obtain an X-ray, check tetanus status, immobilize with a splint, and discharge home with a prescription for antibiotics and analgesics and instructions to follow-up with an orthopedist in 3–5 days
D. Provide parenteral analgesia, obtain an X-ray, check tetanus status, arrange an immediate surgical
consultation for exploration and decompression debridement, and provide prophylactic antibiotics
E. Insert a 14-gauge angiocatheter and aspirate the injected material


Answer: D
Diagnosis: High - pressure injection injury
Discussion: Injection injuries that involve the hand or upper extremity are uncommon but are very high - risk. Most are job - related. The usual mechanism is the injection of fuel oil, grease, cement, paints, or solvents into the body through high - pressure industrial equipment. 

Surgical exploration of the case described in the text.Note the marked tissue edema and damage induced.

The lower the viscosity of the injected substance, the higher  the potential for spread through soft tissue. A pressure of 100 pounds per square inch (psi) can  break the skin. It is not uncommon for airless spray - guns or fuel injectors to generate up to 3,000 – 5,000 psi. The patient who presents with this type of injury is typically a young male with an injury to the nondominant hand. The injured site commonly appears as a small puncture with some surrounding soft tissue swelling. 


Clinicians can sometimes be misled by this benign presentation, which can delay defi nitive care. Care delays can increase the chance of signifi cant functional morbidity and/or loss of limb. Emergent management should include tetanus prophylaxis, analgesia, and broad - spectrum antibiotics. A digital block should not be utilized as this may worsen vascular compromise. Radiographs of the involved areas can help determine the extent of the soft tissue spread of the injected material. Some, but not all, of the injectable materials are radio - opaque. Also, subcutaneous emphysema caused by the high - pressure injection may be appreciated on X - ray. Immediate consultation for surgical decompression (Figure ), exploration, and debridement is required to maximize recovery and functional outcome.

--DrSudeepKC

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