What is Hand High Pressure Injury?
High-pressure injection injuries are a type of orthopedic (bone and muscle) injury that requires quick medical attention and treatment. These injuries may only seem like minor puncture wounds at first glance. However, the injured area can spread under the skin from the fingertip all the way to the chest area, having disastrous effects on the injured limb. Even though these types of injuries are not common, there is plenty of information about them, with the first case reported as far back as 1937. Patients usually end up at trauma centers for treatment, although this is not always the case. This article offers a summary of such injuries, how they’re typically treated, and what factors can impact the outcome.
What Causes Hand High Pressure Injury?
Hand injuries from injections typically happen when a person is cleaning the nozzle of a high-pressure spray gun and it accidentally fires. This can also occur if a person’s skin comes in contact with a leak in the high-pressure piping. Today’s high-pressure cleaning tools can generate very powerful force. It’s as if a 1000 kg weight falls 25 cm onto the finger. The pressure is so powerful that when the liquid penetrates the skin, the contents of the container get quickly expelled into the person’s hand.
In a split second, this substance can travel throughout the hand and potentially reach up to the forearm, without even needing direct contact with the skin. It moves along the ‘fascial planes’, which are layers of connective tissue in the body that surround and support your muscles and organs. What this means is that the injury can become extensive very quickly because of this ability to rapidly spread within the hand and arm.
Risk Factors and Frequency for Hand High Pressure Injury
High-pressure injection injuries are a type of hand trauma that happens about once in every 600 cases seen in the emergency department. These injuries usually occur among young men working in industrial jobs, particularly those working with chemicals such as paint, lubricants, and fuel. This type of injury is most likely to happen on the non-dominant index finger. But, these injuries can also happen on the thumb, palm, and elsewhere on the arms or legs.
There isn’t a clear idea of how often these injuries lead to infection. This might be because doctors usually only take samples to test for infection when signs of infection are visible. In one study, only 126 out of 435 patients had their wound tested for infection, and 53 of these tests came back positive. In that same study, about 31% of the patients whose tests showed an infection had to have the affected limb amputated. It’s estimated that about 30% to 40% of all high-pressure injection injuries result in amputation. This data suggests that the chance of getting an amputation is about the same whether or not the injury is infected.
Signs and Symptoms of Hand High Pressure Injury
People often rush to the emergency department straight from work, complaining about swelling, pain, and a small puncture wound on their hand. Sometimes, these symptoms may not look very serious, causing doctors to initially misdiagnose the problem. In fact, it’s been found that patients often see various doctors for an average of 9 hours before getting the correct diagnosis. Over this period, the patient may experience worsening symptoms like damage to nerves and blood vessels, swelling, and compartment syndrome – a painful condition caused by pressure build-up from internal bleeding or swelling of tissues.
To make a correct diagnosis, doctors need to know specific details about the injury, such as when and how it happened, what tools or machines were involved, the chemical in the injector that caused the injury, and the pressure level of the injection tool, if known.
Although the patient’s recount of their injury can provide valuable clues, doctors also need to thoroughly examine the affected limb and nearby areas. They should check the injured person’s forearm, elbow, upper arm, and armpit to see how far the injury has spread.
A comprehensive examination would include testing the range of motion, observing any changes in skin color, checking pulses, and conducting a complete neurologic examination. The compartments (sections of the arm enclosed by thick skin known as fascia) also need to be rechecked several times, as compartment syndrome can occur hours after the injury due to increased inflammation and swelling.
Testing for Hand High Pressure Injury
In the emergency room, doctors use various methods to understand the nature and severity of an injury. If you’ve experienced an injury, your doctor might look at your white blood cell count. A higher than normal count can indicate a recent injury, and observing how this evolves over time can show how your body is responding to the injury. This might also indicate if there’s a secondary infection.
The doctor could also use an X-ray to see how far an injection or foreign object has traveled into your body. However, this only works if the object shows up on X-ray images. Some substances won’t show up on an X-ray, but they might cause air to get trapped under your skin, which can still be seen on the X-ray.
Doctors also have the option to use CT scans and MRI scans to examine your body tissues closely. However, these tests are usually not needed. These methods help doctors understand your injury, monitor how it’s progressing, and plan the best course of treatment.
Treatment Options for Hand High Pressure Injury
When someone seeks medical care for an injury, they may need a tetanus booster and an antibiotic to prevent infections from both gram-positive and gram-negative bacteria. Strengthening the body’s natural defenses against different types of bacteria is essential in healing. One of these antibiotics might be a third-generation cephalosporin. The injured limb should be gently lifted and cleaned to rid the wound of any larger pieces of debris, but it’s important to leave the wound open to continually drain fluid, and avoid putting any tight bandages or wraps.
Corticosteroids, a type of medication used to relieve inflammation, had been used in the past, but there’s ongoing debate about their use in current medical care. While they could potentially reduce inflammation, there’s concern that they might raise the risk of bacterial infections. More research is needed to understand their benefits and risks completely.
Early surgical cleaning of the wound, known as debridement, is crucial to control inflammation, relieve pressure in the area, and decrease the risk of long-term complications. Delays in performing this surgery have been linked to a higher risk of complications and amputation. This process often involves the removal of all agents that were injected, thorough flushing with saltwater, alleviating pressure buildup, and examining the sheaths of the tendons. Repeat debridements are usually necessary over time until all nonviable tissue and injected material are removed.
In cases where a patient has sustained severe injection injuries, such as ones involving paint or turpentine, some medical experts recommend amputation as the primary treatment. However, this decision should be made based on the doctor’s professional judgment and discussions with the patient.
On the other hand, injection injuries involving air, water, or high-pressure veterinarian vaccines may be treated without surgery and closely watched instead. Surgery to relieve pressure or clean the wound might be postponed unless there’s a risk of compartment syndrome (dangerous pressure buildup in an area) or a secondary infection. Regular check-ups are important to ensure no additional infections develop during recovery. The patient should also be aware that surgical cleaning may still be needed if the non-surgical treatment isn’t beneficial.
What else can Hand High Pressure Injury be?
In non-medical terms, if someone comes to the emergency room saying their hand was fine before an accident, the doctor might suspect several things could be wrong. This might include:
- a severe hand injury caused by a crushing force
- broken bones in the hand or fingers
- a serious condition that causes painful pressure in a muscle compartment in the hand
- a small harmless cut on the finger or palm.
If the person comes to the emergency room a few days after the accident, then the doctor also needs to be concerned about conditions like flexor tenosynovitis, which is an inflammation of the fluid-filled sheath that surrounds a tendon in the hand, or other infections of the fingers and hand.
What to expect with Hand High Pressure Injury
The prognosis or expected outcome for someone who’s had a high-pressure injection injury depends on several factors. These include how quickly the area is cleaned out (debridement), the substance that was injected, how extensive and where the injury is, and the pressure the device released. When a doctor is looking after a patient with this type of injury, these are the points that should be focused on.
Medical professionals don’t entirely agree on how quickly one needs to clean out the wound. Despite this, many studies have shown that the longer the wait before going to the operating room, the more complications there are likely to be. One particular study showed that patients who had been injected with organic solvents like paint thinner were more likely to need an amputation if initial cleaning of the wound was delayed past 6 hours. Another study suggested an increased rate of amputation with delays of over 10 hours. Therefore, it’s generally recognized that the earlier the cleaning, the better, especially when dealing with substances that damage cells (cytotoxic materials) or extensive soft tissue injuries.
The substance that was injected is a crucial factor in these injuries and in figuring out what the overall outcome might be. Injections with organic solvents like turpentine, diesel fuel, and some paint types can cause significant harm to the surrounding soft tissue. One study showed that injections with turpentine led to amputation in 80% of patients, while only 20% of patients injected with grease required amputation. However, injections of air and water have a much better outcome due to their non-cytotoxic properties and usually won’t require surgical cleaning.
It’s also been found that the location of the injection injury impacts the risk of amputation. One researcher pointed out that the risk of amputating fingers was six times greater than the risk for the palm and thumb. This higher risk could be due to several reasons, among which are the surgeon’s tendency to try to keep the thumb’s movement intact and the fact that the thumb and palm have more room for substance injection than the fingers. Injections into the thumb and little finger are also likelier to affect the forearm due to their connections with parts of the hand. On the contrary, injections into the index, middle and ring fingers usually stay confined to a smaller area due to limited space.
It’s not entirely clear if there are specific pressure levels leading to a definite need for amputation. However, several studies have observed that high-pressure injuries are more likely to result in amputations. This may be because high pressure causes worse soft tissue damage and moves more material around the injury site.
Possible Complications When Diagnosed with Hand High Pressure Injury
The complications of this type of injury can include various issues ranging from a decrease in moving ability or function of the limb, potential bacterial infections, long-term granulomas, tissue decay, or even loss of the limb itself. Some people have also reported experiencing chronic pain, abnormal sensitivity to touch, unusual skin sensations, motor dysfunctions, and tightening of muscles long after the injury.
To minimize these complications, it is critical to quickly diagnose the injury, execute an early intervention, and persistently engage in intense physical therapy after surgery.
Common Complications:
- Decreased range of motion or limb function
- Potential bacterial infections
- Long-term granulomas – collections of cells that form when the body fights infections
- Tissue decay
- Loss of the limb
- Chronic pain
- Abnormal sensitivity to touch
- Unusual skin sensations like tingling or prickling
- Motor dysfunctions – problems with the movement and coordination of the limb
- Tightening of muscles leading to limited mobility
Recovery from Hand High Pressure Injury
How a patient is cared for after surgery largely depends on where the injury is, how severe it is, and how much tissue needed to be removed during surgery. The main goals during this time are to help the wound heal and to regain use of the injured limb. The amount of time it takes for a wound to heal can vary depending on the size of the wound and how clean it is. Some methods to speed up the healing process include whirlpool therapy, dressings that are changed from wet to dry, and devices that use vacuum technology, which are all options a surgeon can choose to use. Another method can involve splinting, or supporting, the injured area, which limits movement and can help the wound heal faster.
Regaining function, or use, of the injured limb is another goal, which can only be achieved through consistent physical and occupational therapy. If an amputation was necessary during treatment, training with a prosthetic, or artificial limb, is also important in order to regain use of the limb.
Preventing Hand High Pressure Injury
Those who use high-pressure spraying equipment, either for work or personal use, should be informed about the potential risks of injury. The most common time injuries occur is during the cleaning of the equipment, so extra care should be taken. After an injury, the affected hand might not look too bad, but it’s important not to underestimate the situation. If such an injury occurs, it’s recommended to immediately go to the nearest hospital where there is a surgeon who can properly assess the extent of the high-pressure injection injury.