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Grease-Gun Type Injuries of the Hand
Grease-Gun Type
Injuries of the Hand From the Division of Plastic Surgery, Dartmouth Medical School, and the Hitchcock Clinic, Hanover, New Hampshire
RADFORD C. TANZER, M.D., F.A.C.S. Associate Professor of Plastic Surgery, Dartmouth Medical School; Member, Hitchcock Clinic
PROPER evaluation of the extent of damage and prompt surgical treatment of a grease-gun type injury may well mark the difference between a well-functioning and a completely disabled hand. Lubricants in a high pressure greasing installation may be accidentally expelled in a fine stream from a grease gun attached to a grease fitting at a pressure of 5000 to 7000 lbs.jsq. in., sufficient to cause instant ballooning of tissues through a minute wound of entrance even though the exposed hand be several inches from the tip. Similar pressures exist at the pin-point opening of a diesel engine injector which delivers a chemically irritating oil at the muzzle velocity of a rifle. Mishaps of this type are probably much more numerous than the 26 reported cases would indicate. CLINICAL PATHOLOGY
A grease-gun type injury causes an immediate, tense, painless swelling of the affected part. Penetration of a finger may result in diffuse swelling and blanching of the entire digit, while impregnation of the palm may force grease along fascial planes even up to the elbow." The usual tiny wound of entrance exudes minute quantities of grease although an exploration at this time discloses large pockets of grease with irregular projections pervading the tissues, sometimes actually lying within tendon sheaths. The patient notes immediate restriction of motion and numbness, but the lack of pain masks the seriousness of the injury. Within the next 24 hours the patient develops severe throbbing, Presented before the American Society for Surgery of the Hand, Miami, Florida, January 19, 1963.
1277
1278
RADFORD
c. TANZER
burning pain with signs of acute inflammation and often of circulatory embarrassment in one or more digits. A roentgenogram reveals the presence of subcutenous emphysema and is helpful in determining the extent of involvement.' The early signs are associated with chemical irritation and with acute increase in tissue tension, culminating in abscesses containing grease, and not infrequently in infarction of the digital vessels with necrosis. In the case of impregnation by diesel oil the immediate irritative reaction is much more severe and the incidence of early infarction and gangrene is greater than in cases of lubricating oil injection, although the pressures are similar. Subsidence of the acute phase is usually followed by a long period of disability characterized by recurrent infections, draining sinuses which exude a greasy material, and by the presence of oleomas, rubbery, infiltrative masses, sometimes with softened centers, which may break down and form chronic sinuses. The very late results of the injection of grease and oil into the tissues have been described by Hesse? and Vinogradov'" after studying selfinflicted lesions of 10 to 20 years' duration, principally of the lower extremity, among military personnel. Phlegmonous tumors, severe lymphedema and erysipeloid lesions have frequently necessitated amputation, and in at least one case a squamous epithelioma developed. REPORTED CASES
Since Rees's first report in 1937/5 22 cases of grease-gun in[ury-: 2, 4, 6, 9-13,16-18,20 and four cases of diesel fuel injections- 8, 15 have been reported. The left hand has been involved twice as frequently as the right. The index finger has been penetrated 11 times, the middle finger and palm six times each, and the ring finger thrice. Seven of the 22 cases of grease-gun injection have terminated in partial or complete amputation of a digit, and all four of the diesel oil cases have had amputations (in one case two fingers were removed). The results in the other patients have been almost without exception dismal. Convalescence has often been prolonged over many months, recurrent infections and draining sinuses have been frequent, and stiffness of fingers has been pronounced. TREATMENT
Immediate evacuation of as much foreign material as possible is imperative if prolonged disability is to be avoided. Any involved digit should be widely opened along the midlateralline, all loculations should be identified and grease removed with suction and curette. Tendon sheaths should be unhesitatingly explored and severely impregnated tissues excised if feasible. If the palm is distended it should be widely opened. If grease has been found to penetrate the carpal tunnel one must
Grease-Gun Type Injuries of the Hand
1279
assume that it has invaded Parona's space which should be explored through a longitudinal incision of the ulnar side of the forearm. Stark et al." have advised loose closure of incisions. If it is assumed that some grease remains in inaccessible pockets and that swelling of the hand will be severe, the drainage sites should be left open, as one would do in the case of a fascial space infection, allowing residual grease to be expressed or evacuated. When one is presented with the problem of the secondarily infected hand, wide drainage is indicated to control the acute process, then later the residual mass of scar and encapsulated grease must be approached by painstaking, thorough dissection, oftentimes including the removal of substantial portions of the integument and the employment of pedicle flaps which permit subsequent tendon and nerve reconstruction with some assurance of success. CASE REPORT
A 44 year old operator of a 45-ton caterpillar tractor was injured while loosening the valve of a grease box with a wrench. The tractor had pitched downward into a ditch, throwing its entire weight against the front idler wheels and creating extreme lubricant pressure within the track adjuster reservoir. As the fitting blew off, a thin stream of lubricating grease struck the patient's right hand and orbit. Two hours later an examination revealed a 4 cm. laceration of the ulnar aspect of the palm, due presumably to the impact of the valve. The entire palm was swollen on both volar and dorsal surfaces, and the fingers, which were warm and of good color, were anesthetic over the ulnar nerve distribution. Painless swelling involved the lower half of the- forearm. A 1 cm. laceration of the right upper eyelid was associated with blindness of the right eye, proptosis and diffuse orbital swelling. Roentgenograms demonstrated emphysema of the hand and lower forearm (Fig. 1, A). Exploration of the palm disclosed an irreparable disruption of the ulnar nerve. Approximately 60 cc. of grease were removed from the volar and dorsal fascial spaces of the hand and a similar amount from the forearm deep to the flexor tendons (Fig. 1, B, C). Another 10 cc. were removed from the posterior orbital cavity. Wounds were packed with Vaseline gauze or drained. On the fourth postoperative day edema had subsided markedly but thinner yellowish-brown grease was again expressed from the forearm. Drainage was maintained until the greasy exudate no longer appeared and granulations were healthy. During the seventh week a grease-containing abscess of the dorsum of the hand was drained and necrotic extensor tendons of the ring and little fingers were excised. Scars were revised, the patient resumed work at the end of six months and one month later could make a full fist. One year later a small oleoma of the dorsum of the hand was excised. The brownish-tan specimen consisted of dense, fibrous connective tissue with numerous cysts containing an oily orange liquid. Microscopic study showed fibrous connective tissue permeated with vacuoles of varying size which stained strongly with Sudan III. There were occasional giant cells and lymphocytes, but neither necrosis nor acute inflammatory reaction. The patient has remained free of symptoms for 372 years after injury and has
1280
:aADFORD
C.
TANZER
Fig. 1. A, Roentgenograms on day of injury show dispersion of air through the grease-impregnated tissues. B, C, Incisions for drainage of a grease-gun type injury involving hand and forearm, 9 days postoperatively. Palmar wound was incurred at time of injury.
full use of the hand except for mild flexion contractures of the ring and little fingers (Fig. 2). SUMMARY
The importance of immediate surgical treatment of a grease-gun type injury of the hand is emphasized and a case involving impregnation of , the hand and forearm is described.
Grease-Gun Type Injuries of the Hand
1281
Fig. 2. Range of motion 17 months after injury. The interacting effects of ulnar nerve paralysis and loss of extensor tendons to ring and little fingers have produced tendon balance on the ulnar side of the hand.
DISCUSSION
By
MILTON
T.
EDGERTON,
M.D.
Johns Hopkins University School of Medicine
Dr. Tanzer has pointed out that lubricating oils and diesel oils may be the cause of similar injuries. The grease gun usually contains lubricating oil composed of lime soap and a mineral oil with a large hydrocarbon molecule. In recent years these oils have also contained detergents, extremely irritating to human tissue, which are aimed to keep dirt in suspension. Diesel oils contain smaller molecules than lubricating oils and are generally classified by their cetane (C16H34) rating. Through the mechanism of a pin-point stream of injection, grease may be shot into thehuman hand at pressures of 5000 to 7000 pounds per square inch. Volatilization of the grease may occur on release of pressure. Subcutaneous emphysema is common. The grease may be widely dispersed within the tissue in minute droplets or in some cases may be localized in a single area, as in the case of molten plastic injuries. Thus the injury to the hand comes from one of several mechanisms: necrosis from high speed mechanical impact, delayed chemical injury to the
1282
RADFORD
c. TANZER
tissue, vascular ischemia secondary to pressure within the tissue, and sepsis related to the presence of a contaminated foreign body. The treatment, as indicated by Dr. Tanzer, should be aimed at two principal objectives: saving the circulation and preventing infection. Heat should be avoided and there is recent experimental evidence that hypothermia to the injured part may significantly reduce the oxygen demand of tissue in the days following injury. If vasospasm is conspicuous, sympathectomy may be of considerable value. In the event that a major blood vessel has been permanently damaged in the region of the wrist, an arterial graft routed through uninjured tissues between the forearm and the palmar arch must be considered. The prevention of infection embodies the careful debridement of necrotic tissue and the removal of foreign bodies. Antibiotics should be given and the hands splinted in a position of function. Dr. Tanzer's stressing of early operation and wide surgical exposure seems most important. REFERENCES 1. Bell, R. C.: Grease gun injuries. Brit. J. Plast. Surge 5: 138-145,1952. 2. Brooke, R. and Rooke, C. J.: Two cases of grease-gun finger. Brit. M. J. 2: 1186, 1939. 3. Bunnell, S.: Surgery of the Hand. 3rd Ed. Philadelphia, J. B. Lippincott Co. 1956. 4. Byrne, J. J.: Grease gun injuries. J.A.M.A. 125: 405-407, 1944. 5. Dial, D. E.: Hand injuries due to injection of oil at high pressure. J.A.M.A. 110: 1747,1938. 6. Harrison, R.: "Grease-gun" Injury. Brit. J. Surge 4-6: 514-515, 1959. 7. Hesse, E.: Die chirurgische and gerichtlich-medizinische Bedeutung der kunstlich hervorgerufenen Erkrankungen. Arch. f. kline Chir. 136: 277-291, 1925. 8. Hughes, J. E.: Penetration of tissue by diesel oil under pressure. J.A.M.A. 116:2848-2849,1941. 9. Innes, C. B.: Grease gun finger. New Zealand M. J. 58: 177-178, 1959. 10. Mason, M. L. and Queen, F. B.: Grease gun injuries to the hand. Quart. Bull. Northwestern Univ. M. School 15: 122-132, 1941. 11. Milliken, T. W. and Weston, T. S.: Grease gun injuries. New Zealand M. J. 59: 413-416, 1960. 12. Osborne, J. C.: Grease-gun injury. Canad. J. Surge 3: 339-340,1960. 13. Rains, A. J. H.: Grease-gun injury to the hand. Value of early treatment. Brit. M. J. 1:625-626,1958. 14. Rank, B. K. and Wakefield, A. R.: Surgery of Repair as Applied to Hand Injuries, 2nd Ed. Baltimore, Williams & Wilkins Co., 1960. 15. Rees, C. E.: Penetration of tissue by fuel oil under high pressure from diesel engine. J.A.M.A. 109: 866-867, 1937. 16. Smith, F. H.: Penetration of tissue by grease under pressure of 7000 pounds. J.A.M.A. 112: 907-908, 1939. 17. Stark, H. H., Wilson, J. N. and Boyes, J. H.: Grease-gun injuries of the hand. J. Bone & Joint Surge 43A: 485-491, 1961. 18. Tempest, M. N.: Grease-gun injuries. Univ. Leeds M. J. 2: 125-129,1953. 19. Vinogradov, 1.: Uber Spatfolgen kimstlicher Oleogranulome. Arch. f. kline Chir. 187: 69-78, 1936. 20. Vivian, D. N. and Christian, S. G.: Grease gun injury. Indust. Med. & Surg. 25:282-284,1956.
Injuries of the Hand From the Division of Plastic Surgery, Dartmouth Medical School, and the Hitchcock Clinic, Hanover, New Hampshire
RADFORD C. TANZER, M.D., F.A.C.S. Associate Professor of Plastic Surgery, Dartmouth Medical School; Member, Hitchcock Clinic
PROPER evaluation of the extent of damage and prompt surgical treatment of a grease-gun type injury may well mark the difference between a well-functioning and a completely disabled hand. Lubricants in a high pressure greasing installation may be accidentally expelled in a fine stream from a grease gun attached to a grease fitting at a pressure of 5000 to 7000 lbs.jsq. in., sufficient to cause instant ballooning of tissues through a minute wound of entrance even though the exposed hand be several inches from the tip. Similar pressures exist at the pin-point opening of a diesel engine injector which delivers a chemically irritating oil at the muzzle velocity of a rifle. Mishaps of this type are probably much more numerous than the 26 reported cases would indicate. CLINICAL PATHOLOGY
A grease-gun type injury causes an immediate, tense, painless swelling of the affected part. Penetration of a finger may result in diffuse swelling and blanching of the entire digit, while impregnation of the palm may force grease along fascial planes even up to the elbow." The usual tiny wound of entrance exudes minute quantities of grease although an exploration at this time discloses large pockets of grease with irregular projections pervading the tissues, sometimes actually lying within tendon sheaths. The patient notes immediate restriction of motion and numbness, but the lack of pain masks the seriousness of the injury. Within the next 24 hours the patient develops severe throbbing, Presented before the American Society for Surgery of the Hand, Miami, Florida, January 19, 1963.
1277
1278
RADFORD
c. TANZER
burning pain with signs of acute inflammation and often of circulatory embarrassment in one or more digits. A roentgenogram reveals the presence of subcutenous emphysema and is helpful in determining the extent of involvement.' The early signs are associated with chemical irritation and with acute increase in tissue tension, culminating in abscesses containing grease, and not infrequently in infarction of the digital vessels with necrosis. In the case of impregnation by diesel oil the immediate irritative reaction is much more severe and the incidence of early infarction and gangrene is greater than in cases of lubricating oil injection, although the pressures are similar. Subsidence of the acute phase is usually followed by a long period of disability characterized by recurrent infections, draining sinuses which exude a greasy material, and by the presence of oleomas, rubbery, infiltrative masses, sometimes with softened centers, which may break down and form chronic sinuses. The very late results of the injection of grease and oil into the tissues have been described by Hesse? and Vinogradov'" after studying selfinflicted lesions of 10 to 20 years' duration, principally of the lower extremity, among military personnel. Phlegmonous tumors, severe lymphedema and erysipeloid lesions have frequently necessitated amputation, and in at least one case a squamous epithelioma developed. REPORTED CASES
Since Rees's first report in 1937/5 22 cases of grease-gun in[ury-: 2, 4, 6, 9-13,16-18,20 and four cases of diesel fuel injections- 8, 15 have been reported. The left hand has been involved twice as frequently as the right. The index finger has been penetrated 11 times, the middle finger and palm six times each, and the ring finger thrice. Seven of the 22 cases of grease-gun injection have terminated in partial or complete amputation of a digit, and all four of the diesel oil cases have had amputations (in one case two fingers were removed). The results in the other patients have been almost without exception dismal. Convalescence has often been prolonged over many months, recurrent infections and draining sinuses have been frequent, and stiffness of fingers has been pronounced. TREATMENT
Immediate evacuation of as much foreign material as possible is imperative if prolonged disability is to be avoided. Any involved digit should be widely opened along the midlateralline, all loculations should be identified and grease removed with suction and curette. Tendon sheaths should be unhesitatingly explored and severely impregnated tissues excised if feasible. If the palm is distended it should be widely opened. If grease has been found to penetrate the carpal tunnel one must
Grease-Gun Type Injuries of the Hand
1279
assume that it has invaded Parona's space which should be explored through a longitudinal incision of the ulnar side of the forearm. Stark et al." have advised loose closure of incisions. If it is assumed that some grease remains in inaccessible pockets and that swelling of the hand will be severe, the drainage sites should be left open, as one would do in the case of a fascial space infection, allowing residual grease to be expressed or evacuated. When one is presented with the problem of the secondarily infected hand, wide drainage is indicated to control the acute process, then later the residual mass of scar and encapsulated grease must be approached by painstaking, thorough dissection, oftentimes including the removal of substantial portions of the integument and the employment of pedicle flaps which permit subsequent tendon and nerve reconstruction with some assurance of success. CASE REPORT
A 44 year old operator of a 45-ton caterpillar tractor was injured while loosening the valve of a grease box with a wrench. The tractor had pitched downward into a ditch, throwing its entire weight against the front idler wheels and creating extreme lubricant pressure within the track adjuster reservoir. As the fitting blew off, a thin stream of lubricating grease struck the patient's right hand and orbit. Two hours later an examination revealed a 4 cm. laceration of the ulnar aspect of the palm, due presumably to the impact of the valve. The entire palm was swollen on both volar and dorsal surfaces, and the fingers, which were warm and of good color, were anesthetic over the ulnar nerve distribution. Painless swelling involved the lower half of the- forearm. A 1 cm. laceration of the right upper eyelid was associated with blindness of the right eye, proptosis and diffuse orbital swelling. Roentgenograms demonstrated emphysema of the hand and lower forearm (Fig. 1, A). Exploration of the palm disclosed an irreparable disruption of the ulnar nerve. Approximately 60 cc. of grease were removed from the volar and dorsal fascial spaces of the hand and a similar amount from the forearm deep to the flexor tendons (Fig. 1, B, C). Another 10 cc. were removed from the posterior orbital cavity. Wounds were packed with Vaseline gauze or drained. On the fourth postoperative day edema had subsided markedly but thinner yellowish-brown grease was again expressed from the forearm. Drainage was maintained until the greasy exudate no longer appeared and granulations were healthy. During the seventh week a grease-containing abscess of the dorsum of the hand was drained and necrotic extensor tendons of the ring and little fingers were excised. Scars were revised, the patient resumed work at the end of six months and one month later could make a full fist. One year later a small oleoma of the dorsum of the hand was excised. The brownish-tan specimen consisted of dense, fibrous connective tissue with numerous cysts containing an oily orange liquid. Microscopic study showed fibrous connective tissue permeated with vacuoles of varying size which stained strongly with Sudan III. There were occasional giant cells and lymphocytes, but neither necrosis nor acute inflammatory reaction. The patient has remained free of symptoms for 372 years after injury and has
1280
:aADFORD
C.
TANZER
Fig. 1. A, Roentgenograms on day of injury show dispersion of air through the grease-impregnated tissues. B, C, Incisions for drainage of a grease-gun type injury involving hand and forearm, 9 days postoperatively. Palmar wound was incurred at time of injury.
full use of the hand except for mild flexion contractures of the ring and little fingers (Fig. 2). SUMMARY
The importance of immediate surgical treatment of a grease-gun type injury of the hand is emphasized and a case involving impregnation of , the hand and forearm is described.
Grease-Gun Type Injuries of the Hand
1281
Fig. 2. Range of motion 17 months after injury. The interacting effects of ulnar nerve paralysis and loss of extensor tendons to ring and little fingers have produced tendon balance on the ulnar side of the hand.
DISCUSSION
By
MILTON
T.
EDGERTON,
M.D.
Johns Hopkins University School of Medicine
Dr. Tanzer has pointed out that lubricating oils and diesel oils may be the cause of similar injuries. The grease gun usually contains lubricating oil composed of lime soap and a mineral oil with a large hydrocarbon molecule. In recent years these oils have also contained detergents, extremely irritating to human tissue, which are aimed to keep dirt in suspension. Diesel oils contain smaller molecules than lubricating oils and are generally classified by their cetane (C16H34) rating. Through the mechanism of a pin-point stream of injection, grease may be shot into thehuman hand at pressures of 5000 to 7000 pounds per square inch. Volatilization of the grease may occur on release of pressure. Subcutaneous emphysema is common. The grease may be widely dispersed within the tissue in minute droplets or in some cases may be localized in a single area, as in the case of molten plastic injuries. Thus the injury to the hand comes from one of several mechanisms: necrosis from high speed mechanical impact, delayed chemical injury to the
1282
RADFORD
c. TANZER
tissue, vascular ischemia secondary to pressure within the tissue, and sepsis related to the presence of a contaminated foreign body. The treatment, as indicated by Dr. Tanzer, should be aimed at two principal objectives: saving the circulation and preventing infection. Heat should be avoided and there is recent experimental evidence that hypothermia to the injured part may significantly reduce the oxygen demand of tissue in the days following injury. If vasospasm is conspicuous, sympathectomy may be of considerable value. In the event that a major blood vessel has been permanently damaged in the region of the wrist, an arterial graft routed through uninjured tissues between the forearm and the palmar arch must be considered. The prevention of infection embodies the careful debridement of necrotic tissue and the removal of foreign bodies. Antibiotics should be given and the hands splinted in a position of function. Dr. Tanzer's stressing of early operation and wide surgical exposure seems most important. REFERENCES 1. Bell, R. C.: Grease gun injuries. Brit. J. Plast. Surge 5: 138-145,1952. 2. Brooke, R. and Rooke, C. J.: Two cases of grease-gun finger. Brit. M. J. 2: 1186, 1939. 3. Bunnell, S.: Surgery of the Hand. 3rd Ed. Philadelphia, J. B. Lippincott Co. 1956. 4. Byrne, J. J.: Grease gun injuries. J.A.M.A. 125: 405-407, 1944. 5. Dial, D. E.: Hand injuries due to injection of oil at high pressure. J.A.M.A. 110: 1747,1938. 6. Harrison, R.: "Grease-gun" Injury. Brit. J. Surge 4-6: 514-515, 1959. 7. Hesse, E.: Die chirurgische and gerichtlich-medizinische Bedeutung der kunstlich hervorgerufenen Erkrankungen. Arch. f. kline Chir. 136: 277-291, 1925. 8. Hughes, J. E.: Penetration of tissue by diesel oil under pressure. J.A.M.A. 116:2848-2849,1941. 9. Innes, C. B.: Grease gun finger. New Zealand M. J. 58: 177-178, 1959. 10. Mason, M. L. and Queen, F. B.: Grease gun injuries to the hand. Quart. Bull. Northwestern Univ. M. School 15: 122-132, 1941. 11. Milliken, T. W. and Weston, T. S.: Grease gun injuries. New Zealand M. J. 59: 413-416, 1960. 12. Osborne, J. C.: Grease-gun injury. Canad. J. Surge 3: 339-340,1960. 13. Rains, A. J. H.: Grease-gun injury to the hand. Value of early treatment. Brit. M. J. 1:625-626,1958. 14. Rank, B. K. and Wakefield, A. R.: Surgery of Repair as Applied to Hand Injuries, 2nd Ed. Baltimore, Williams & Wilkins Co., 1960. 15. Rees, C. E.: Penetration of tissue by fuel oil under high pressure from diesel engine. J.A.M.A. 109: 866-867, 1937. 16. Smith, F. H.: Penetration of tissue by grease under pressure of 7000 pounds. J.A.M.A. 112: 907-908, 1939. 17. Stark, H. H., Wilson, J. N. and Boyes, J. H.: Grease-gun injuries of the hand. J. Bone & Joint Surge 43A: 485-491, 1961. 18. Tempest, M. N.: Grease-gun injuries. Univ. Leeds M. J. 2: 125-129,1953. 19. Vinogradov, 1.: Uber Spatfolgen kimstlicher Oleogranulome. Arch. f. kline Chir. 187: 69-78, 1936. 20. Vivian, D. N. and Christian, S. G.: Grease gun injury. Indust. Med. & Surg. 25:282-284,1956.