MANUAL MINORS
High-pressure injection injuries occur when a substance, such as oil, paint, grease, or air, is accidentally injected into the soft tissues of the hand or fingers at high speed by a high-pressure tool or device.
Although these injuries may initially seem benign, they can be devastating, as the injected substance rapidly spreads through the tissues, causing extensive damage to muscles, tendons, nerves, and blood vessels. There is also a high risk of infection and necrosis, which can endanger the viability of the affected limb if not managed quickly.
Diagnosis
The diagnosis of high-pressure injection injuries is based on the patient’s clinical history (commonly industrial or mechanical workers) and physical examination. Immediately after the injury, external signs may be minimal, with only a small entry wound visible.
However, the patient typically reports pain disproportionate to the appearance of the wound. In the hours following, the hand may swell, become painful, and show discolouration due to tissue and vascular damage.
A radiograph should be performed to detect the spread of air or foreign material in the tissues, and in some cases, computed tomography (CT) may provide more details about the extent of the damage.
Differential Diagnosis
Condition | Main Clinical Characteristics | Key Differentiation |
|---|---|---|
Simple contusion | Pain, swelling, without deep penetration | Absence of foreign material or visible spread |
Acute infection | Swelling, erythema, warmth, and progressive pain | History of infection or wound without high-pressure injection |
Animal bite | Open wound with signs of infection | History of bite, no machinery involved |
Vascular injury | Distal pallor or coolness | History of vascular trauma without injected substance |
Subcutaneous foreign body | Localised pain, often visible on X-rays | History of object penetration without high-pressure use |
Emergency Management
Initial management of high-pressure injection injuries is a surgical emergency. Despite the minor appearance on the surface, the injected substance may be causing severe internal damage. Immediate treatment includes:
Immobilisation of the limb: To prevent further spread of the injected material.
Analgesia: Administration of strong painkillers, as these injuries are usually extremely painful.
Antibiotic prophylaxis: Broad-spectrum antibiotics are administered preventively due to the high risk of infection from the injected material.
Urgent surgical referral: The patient should be rapidly transferred to a centre where a hand surgeon can perform exploration and extensive debridement of the affected tissue. Surgical washing is essential to remove the injected substance and minimise tissue damage.
It is crucial not to underestimate these injuries and avoid delays in surgical intervention, as this can lead to serious complications such as deep infections, tissue necrosis, or even amputations.
Definitive Treatment
Definitive treatment involves aggressive surgical debridement of the affected area to remove all injected material. Depending on the type and extent of the injury, multiple surgeries may be necessary. In some cases, fasciotomies are required to release pressure in the hand compartments and prevent compartment syndrome.
Postoperative care includes antibiotics, rehabilitation therapy, and in some cases, skin grafts or reconstructive surgery if significant tissue damage has occurred. Recovery may be prolonged, and in the most severe cases, there may be permanent functional loss of the hand or even amputation.
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