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High - pressure spray gun injection injuries of the hand
EMERGENCY CASE REP,ORTS
H igh- pressure spray gun injection injuries of the hand Mark S. Slonim, MD Richard M. Braun, MD Brian A. Roper, MD, FRCS San Diego, California High-pressure spray guns produce hand injury by a combination of direct mechanical impact, ischemia secondary to vascular necrosis, and tissue toxicity of the injected material. Complications include infection, ischemic compartment syndromes, and la!e-draining sinuses. The seriousness of the injury is not usually apparent on initial examination. Two cases are reported In which severe and crippling injury arose from what at first appeared to be an innocuous wound. Proper initial management depends upon recognition of the hazard in this benign picture so that vigorous surgical debrldement and decompression may be accomplished without delay. Numerous recent reports document potential hazards of highpressure injection gun injuries. 1-s
Fig. 1.
High-pressure spray gun.
Spray nozzle pressures as high as 2000 Ibs/inch = can be developed by these spray gun units. The dangers inherent in an accidental injection occurring through careless use are far from minimal. An injection injury of
the hand must be recognized as a dire surgical emergency despite an innocuous appearance of the injured area immediately following the accident. That physicians may find such injuries deceptively benign at the time of initial examination is illustrated by the following case reports: CASE 1. A 55-year-old man was seen in the emergency department i m m e d i a t e l y f o l l o w i n g a highpressure spray gun injury of the index finger. The gun had contained latex paint. Signs were minimal and he was discharged without treatment. He was seen by his family physician, complaining of pain in the finger, on the following day. Conservative treatment was advised. On the second day following the injury, because of continuous and severe pain in the finger, he was referred for an orthopedic consultation. The finger appeared as CASE
NO.
shown in Figure 2. Surgical decom. pression was performed several hours later with the removal of the 3day-old Ioculated latex paint (Fig 3). While the finger was saved, it re. mained stiff and painful. One year following the injury it was amputated at the patient's request.
CASE 2. A shipworker was cleaning paint from pressure-spray equipment using a solvent to clear the line. He accidently sprayed solvent into the flexion crease of his right index finger. Immediately following the injury he was seen in the local emergency department complaining of severe pain in his finger and palm. The physician on duty, noting the trivial appearance of the wound (Fig 4), provided a band aid for therapy and prepared to discharge the patient. The emergency department nurse suggested caution be taken and an orthopedic consultation was requested. The patient was taken to surgery within three hours and primary debridement was performed. Five days later, due to the extreme toxicity of the solvent, the finger was no longer viable (Fig 5). The entire web space between the thumb and index finger was also necrotic and there
1
Submitted for publication December 27, 1972 Address for reprints: Richard M. Braun, MD, Hillcrest Orthopaedic Medical Group, Suite 229, 550 Washington Street, San Diego, California 92103 Page 116
Fig. 2.
Innocuous wound.
Journal of the American College of Emergency Physicians
Mar/Apr 1973
were multiple areas of loss of the full thickness of skin on both dorsal and palmar surfaces. A chemical cellulitis had spread into the forearm (Fig 6). ,1"he patient was febrile with tender palpable nodes at the elbow and in the axilla. While the devastating toxicity of the chemical solvent was responsible for the local and systemic problem, the wound had already been invaded by pseudomonas organisms. Amputation of the index finger ray and web-space was required with later coverage by skin grafts and pedicle flaps. Widespread use of high-pressure sprays in industry has led to reports of injury due to injection with grease, paint, industrial solvents, plastic, tear gas, cement, and various other materials. In addition, numerous paint spray devices are now available to large segments of the population for occasional use in home maintenance and hobby work (Fig. 1). It seems inevitable that the incidence of these injuries will increase. The anatomy of the hand in relation to the special nature of the forces and features of the injection gun has led several clinical investigators to study experimental injury in cadaver specimens. Kaufman 6 injected wax at 750 Ibs/inch 2 into cadaver hands using a commercial high-pressure paint spray gun. When these specimens were dissected it was found that the initial mass of material which perIorated the skin dissected locally along tissue planes. Primary spread {0 the superficial fat layer was noted, as well as spread into deeper tissues. If the spray was directed at an area where subcutaneous coverage of a tendon sheath was minimal such as the middle joint flexion crease, the material would spread into the tendon Sheath and thence proximally into the palm where it would rupture into the deeper palmar space. Injection into the Subcutaneous portion of the finger WOuld allow the material to track dorSally where it could spread freely beneath the skin in the dorsal fat laYer. Latex paint, the injuring material injected in Case 1, will track in a manner similar to that predicted by this hot wax study. ~4ar/Apr 1973
CASE
NO.
2
Fig. 4.
Trivial appearance of wound site conceals deep penetration of toxic solvent within hand.
Fig. 5.
Toxic reaction from solvent has caused entire web space between thumb and index finger to become necrotic. Note also the areas in which full thickness of skin will be lost.
Wax injection studies can not reproduce the seriousness of an in vivo injection of an industrial solvent since wax has but a limited ability to penetrate tissue. In the clinicat situation paint solvents, the chemical responsible for the injury in Case 2,
will penetrate fascia and muscle tissue readily, thus causing damage to structures far distant from the area of injection. Deep muscle necrosis and blood vessel destruction may occur at a late stage. These often lead to amputation, after a period of several
Journal of the American College of Emergency Physicians
Page 117
S P R A Y GUN I N J U R I E S
weeks, because of loss of viability, the progressive effect of injury from the inoculation. High-pressure spray guns produce tissue damage by a combination of direct mechanical impact, ischemia secondary to vessel necrosis and biocidal potency of the injected material. Secondary complications, such as ischemic compartment syndromes, are not uncommon. Superimposed infections may further c o m p l i c a t e t h e p r o b l e m . . Latedraining sinuses and continuous tissue destruction have been reported by Mason and Queen 7 who describe granuloma formation with retained grease in the deep structures of the hand. Vigorous initial treatment is essential to :minimize the effect of these serious injuries. The innocuous appearance of an injected digit following an accident is illustrated in Figs. 2 and 4. Surgical debridement is mandatory in these cases as it offers the only opportunity to remove the foreign material, which may be directly histotoxic. Early surgery affords the
Page 118
opportunity to decompress muscles, nerves and vascular structures within the hand. The most difficult substances to deal with are those c o l o r l e s s l i q u i d s such as paint solvents, turpentine and other industrial solvents, which have an extremely low viscosity and spread rapidly through tissue. The initial surgical procedure concerns itself with debridement and decompression. After this, the patient is carefully observed regarding the systemic manifestations of the injection, including the onset of lymphangitis and bacterial contamination. Necrotic areas are debrided and when major areas of skin loss occur, complex soft tissue closures, including skin grafts and pedicle flaps may be necessary in an attempt to provide adequate coverage. The prognosis for a finger which has sustained major injury with a high-pressure spray gun is extremely grave. It is reasonable to advise the patient of this fact on his initial examination. The benign appearance of the wound on initial examination
poses a distinct hazard that cannot be overstressed. It suggests to the physician, and to the patient as well, that the injury is of little import. The two cases illustrated here are not atypical. Delays in treatment may be disastrous. The key to appropriate management is early recognition of the magnitude of the threat to total hand function from an apparently in. nocuous wound.
REFERENCES 1. Adams JP, Fee N, Kenmore Pl:Tear gas injuries. J Bone Joint Surg. 48A:436, 1966. 2. Stark HH, Wilson JN, Boyes JH: Grease gun injuries of the hand. J Bone Joint Surg. 43A:485, 1961. 3. Blue AI, Distine MJ: Grease gun damage. Northwest Med. 64:342, 1965. 4. Tanzer RC: Grease-gun type in. juries of the hand. Surg Clin North Am 43:1277, 1963. 5. Stark HH, Ashworth CR, Boyes JH: Paint gun injuries of the hand. J Bone Joint Surg 49A:637, 1967. 6. Kaufman HD: The anatomy of ex. perimentally produced high-pressure in. jection injuries of the hand. Br J Surg 55:340, 1968. 7. Mason MD, Queen FB: Grease gun injuries to the hand. Quart Bull Northwest Univ. Med. School. 15:122, 1941.
Journal of the American College of Emergency Physicians
M a r / A p r 1973
H igh- pressure spray gun injection injuries of the hand Mark S. Slonim, MD Richard M. Braun, MD Brian A. Roper, MD, FRCS San Diego, California High-pressure spray guns produce hand injury by a combination of direct mechanical impact, ischemia secondary to vascular necrosis, and tissue toxicity of the injected material. Complications include infection, ischemic compartment syndromes, and la!e-draining sinuses. The seriousness of the injury is not usually apparent on initial examination. Two cases are reported In which severe and crippling injury arose from what at first appeared to be an innocuous wound. Proper initial management depends upon recognition of the hazard in this benign picture so that vigorous surgical debrldement and decompression may be accomplished without delay. Numerous recent reports document potential hazards of highpressure injection gun injuries. 1-s
Fig. 1.
High-pressure spray gun.
Spray nozzle pressures as high as 2000 Ibs/inch = can be developed by these spray gun units. The dangers inherent in an accidental injection occurring through careless use are far from minimal. An injection injury of
the hand must be recognized as a dire surgical emergency despite an innocuous appearance of the injured area immediately following the accident. That physicians may find such injuries deceptively benign at the time of initial examination is illustrated by the following case reports: CASE 1. A 55-year-old man was seen in the emergency department i m m e d i a t e l y f o l l o w i n g a highpressure spray gun injury of the index finger. The gun had contained latex paint. Signs were minimal and he was discharged without treatment. He was seen by his family physician, complaining of pain in the finger, on the following day. Conservative treatment was advised. On the second day following the injury, because of continuous and severe pain in the finger, he was referred for an orthopedic consultation. The finger appeared as CASE
NO.
shown in Figure 2. Surgical decom. pression was performed several hours later with the removal of the 3day-old Ioculated latex paint (Fig 3). While the finger was saved, it re. mained stiff and painful. One year following the injury it was amputated at the patient's request.
CASE 2. A shipworker was cleaning paint from pressure-spray equipment using a solvent to clear the line. He accidently sprayed solvent into the flexion crease of his right index finger. Immediately following the injury he was seen in the local emergency department complaining of severe pain in his finger and palm. The physician on duty, noting the trivial appearance of the wound (Fig 4), provided a band aid for therapy and prepared to discharge the patient. The emergency department nurse suggested caution be taken and an orthopedic consultation was requested. The patient was taken to surgery within three hours and primary debridement was performed. Five days later, due to the extreme toxicity of the solvent, the finger was no longer viable (Fig 5). The entire web space between the thumb and index finger was also necrotic and there
1
Submitted for publication December 27, 1972 Address for reprints: Richard M. Braun, MD, Hillcrest Orthopaedic Medical Group, Suite 229, 550 Washington Street, San Diego, California 92103 Page 116
Fig. 2.
Innocuous wound.
Journal of the American College of Emergency Physicians
Mar/Apr 1973
were multiple areas of loss of the full thickness of skin on both dorsal and palmar surfaces. A chemical cellulitis had spread into the forearm (Fig 6). ,1"he patient was febrile with tender palpable nodes at the elbow and in the axilla. While the devastating toxicity of the chemical solvent was responsible for the local and systemic problem, the wound had already been invaded by pseudomonas organisms. Amputation of the index finger ray and web-space was required with later coverage by skin grafts and pedicle flaps. Widespread use of high-pressure sprays in industry has led to reports of injury due to injection with grease, paint, industrial solvents, plastic, tear gas, cement, and various other materials. In addition, numerous paint spray devices are now available to large segments of the population for occasional use in home maintenance and hobby work (Fig. 1). It seems inevitable that the incidence of these injuries will increase. The anatomy of the hand in relation to the special nature of the forces and features of the injection gun has led several clinical investigators to study experimental injury in cadaver specimens. Kaufman 6 injected wax at 750 Ibs/inch 2 into cadaver hands using a commercial high-pressure paint spray gun. When these specimens were dissected it was found that the initial mass of material which perIorated the skin dissected locally along tissue planes. Primary spread {0 the superficial fat layer was noted, as well as spread into deeper tissues. If the spray was directed at an area where subcutaneous coverage of a tendon sheath was minimal such as the middle joint flexion crease, the material would spread into the tendon Sheath and thence proximally into the palm where it would rupture into the deeper palmar space. Injection into the Subcutaneous portion of the finger WOuld allow the material to track dorSally where it could spread freely beneath the skin in the dorsal fat laYer. Latex paint, the injuring material injected in Case 1, will track in a manner similar to that predicted by this hot wax study. ~4ar/Apr 1973
CASE
NO.
2
Fig. 4.
Trivial appearance of wound site conceals deep penetration of toxic solvent within hand.
Fig. 5.
Toxic reaction from solvent has caused entire web space between thumb and index finger to become necrotic. Note also the areas in which full thickness of skin will be lost.
Wax injection studies can not reproduce the seriousness of an in vivo injection of an industrial solvent since wax has but a limited ability to penetrate tissue. In the clinicat situation paint solvents, the chemical responsible for the injury in Case 2,
will penetrate fascia and muscle tissue readily, thus causing damage to structures far distant from the area of injection. Deep muscle necrosis and blood vessel destruction may occur at a late stage. These often lead to amputation, after a period of several
Journal of the American College of Emergency Physicians
Page 117
S P R A Y GUN I N J U R I E S
weeks, because of loss of viability, the progressive effect of injury from the inoculation. High-pressure spray guns produce tissue damage by a combination of direct mechanical impact, ischemia secondary to vessel necrosis and biocidal potency of the injected material. Secondary complications, such as ischemic compartment syndromes, are not uncommon. Superimposed infections may further c o m p l i c a t e t h e p r o b l e m . . Latedraining sinuses and continuous tissue destruction have been reported by Mason and Queen 7 who describe granuloma formation with retained grease in the deep structures of the hand. Vigorous initial treatment is essential to :minimize the effect of these serious injuries. The innocuous appearance of an injected digit following an accident is illustrated in Figs. 2 and 4. Surgical debridement is mandatory in these cases as it offers the only opportunity to remove the foreign material, which may be directly histotoxic. Early surgery affords the
Page 118
opportunity to decompress muscles, nerves and vascular structures within the hand. The most difficult substances to deal with are those c o l o r l e s s l i q u i d s such as paint solvents, turpentine and other industrial solvents, which have an extremely low viscosity and spread rapidly through tissue. The initial surgical procedure concerns itself with debridement and decompression. After this, the patient is carefully observed regarding the systemic manifestations of the injection, including the onset of lymphangitis and bacterial contamination. Necrotic areas are debrided and when major areas of skin loss occur, complex soft tissue closures, including skin grafts and pedicle flaps may be necessary in an attempt to provide adequate coverage. The prognosis for a finger which has sustained major injury with a high-pressure spray gun is extremely grave. It is reasonable to advise the patient of this fact on his initial examination. The benign appearance of the wound on initial examination
poses a distinct hazard that cannot be overstressed. It suggests to the physician, and to the patient as well, that the injury is of little import. The two cases illustrated here are not atypical. Delays in treatment may be disastrous. The key to appropriate management is early recognition of the magnitude of the threat to total hand function from an apparently in. nocuous wound.
REFERENCES 1. Adams JP, Fee N, Kenmore Pl:Tear gas injuries. J Bone Joint Surg. 48A:436, 1966. 2. Stark HH, Wilson JN, Boyes JH: Grease gun injuries of the hand. J Bone Joint Surg. 43A:485, 1961. 3. Blue AI, Distine MJ: Grease gun damage. Northwest Med. 64:342, 1965. 4. Tanzer RC: Grease-gun type in. juries of the hand. Surg Clin North Am 43:1277, 1963. 5. Stark HH, Ashworth CR, Boyes JH: Paint gun injuries of the hand. J Bone Joint Surg 49A:637, 1967. 6. Kaufman HD: The anatomy of ex. perimentally produced high-pressure in. jection injuries of the hand. Br J Surg 55:340, 1968. 7. Mason MD, Queen FB: Grease gun injuries to the hand. Quart Bull Northwest Univ. Med. School. 15:122, 1941.
Journal of the American College of Emergency Physicians
M a r / A p r 1973