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Neurovascular island flap reconstruction following high pressure injection injuries of the hand
Inju~.13. 18 l-l 84
181
Printedin Great Britain
Neurovascular island flap reconstruction following high pressure injection injuries of the hand Joel Engel and Eran Lin Hand Surgery Unit, The Chaim Sheba Medical Center, Tel Hashomer, Israel
Haggai Tsur Department of Plastic Surgery, Sackler School of Medicine, Tel A viv University, Israel
Summary
Adequate, satisfactory treatment of high pressure paint or grease injection of the hand invariably requires wide wound excision. This results quite ofien in a mutilated, disabled digit or hand, with loss of soft tissue and sensation. We report two such cases, each with a neurovascular island flap used in order to restore
adequate soft tissue and sensation. INTRODUCTION
SINCEthe first report of a high pressure injection injury of the hand by Rees in 1937, about 130 additional cases have been reported in Englishlanguage medical literature (Schoo et al., 1980). All papers emphasize the importance of early and adequate drainage and of extensive wound excision but there are few reviews of the final functional results. In the cases reported here, the patients required a number of operations in order to salvage the injured finger. After recovery from the initial procedures, both were left with disability due to loss of soft tissue and sensation. Reconstruction was then performed with a neurovascular island flap. To our knowledge, these are the first two such cases of high pressure injection injuries treated in such a manner to be reported in the medical literature.
CASE
REPORTS
Case 1
A 2%year-old man injured his right thumb with a high pressure paint gun. The pressure emitted by the gun was about 24 150 kPa. Two hours later the patient was seen in the emergency room by a house doctor who, being unfamiliar with high pressure injuries and unimpressed by the minimal clinical findings, treated the patient with tetanus toxoid and discharged him. The patient returned to the hospital the following day with severe swelling of the thumb and entire hand. A small black area, about 3 cm in diameter, was noticed on the pulp of the thumb. No signs of lymphangitis or lymphadenopathy were present. The patient was taken to the operating room and under intravenous block anaesthesia, a small palmar incision was made, which yielded large amounts of paint. Despite high doses of antibiotics, the infection failed to improve and 6 days later the hand was again explored. This time a wide exploration of the thumb and hand was performed with extensive removal of paint and necrotic soft tissue, including the flexor tendons and sheath. The wounds healed without complication, but the patient suffered from loss of sensation of the thumb. Ten months following the injury, reconstruction was performed by transferring an island flap from the ulnar aspect of the long finger to the tip of the thumb. Four months later, the patient returned to his original occupation as a driver. He demonstrated a full range of motion of the thumb, except for stiffness at the interphalangeal joint, and has good protective sensation of
182
tnjury: the Brrttsh Journal of Accident Surgery Vol. 1 ~/NO. 3
b Fig. I. Case 1. a, Final result, 1 year after transfer of island flap from the long finger to the thumb. (Flap and donor areas are circumscribed in black.) b. Close-up appearance of the thumb I year following transfer of the island flap. the thumb. He occasionally still confuses the thumb with the long finger. (See Fig. I .) Case 2 A 2 I -year-old man sustained a paint gun injury to the pulp of his index, of the left (non-dominant) hand. He was immediately admitted to the hospital and a few hours following the injury the index was explored under general anaesthesia through a zig-zag incision. The paint was found to penetrate from the point of entry at the tip of the finger to the level of the phalanx, involving the radial neurovascular bundle, but sparing the flexor tendon sheath. Extensive wound excision and irrigation were performed. All paint and damaged tissues were removed. Ten days later the patient was again operated on because of persistent infection. Following additional wound toilet, a fairly large area of skin loss was present on the volar aspect of the finger. A cross-finger flap was performed in order to cover the defect. Healing was uneventful. However, the anaesthetic flap handicapped the patient and 6 months later a neurovascular island flap was raised fromthe ulnar aspect of the long finger to replace the anaesthetic area of the index. Nine months following the injury, the patient returned to his normal occupation as a painter of automobiles, and has full sensation of the index, with good localization of touch as well as a good range of movement of the finger. (See Fig. 2.)
DISCUSSION High pressure paint and grease gun injuries of in modern the hand have become common
industry. Usually the material is injected into the index finger of the non-dominant hand (Gelberman et al., 1975; Dickson, 1976; Kaufman, 1968; Kaufman, 1970) at a pressure of 20 700-69 000 kPa. (Gillepsie et al., 1974; Schoo et al., 1980). The initial wound appears to the inexperienced observer to be a negligibly small injury; but within a few hours, the affected digit becomes swollen, severely painful, and starts to demonstrate early ischaemic changes (Rees, 1937; Gillepsie et al., 1974; Schoo et al., 1980). Lack of treatment, or inappropriate or inadequate care, will lead to necrosis and eventual amputation. Such a course of events is not an unusual occurrence when the patient, on being brought to an emergency room, is observed by an inexperienced young house doctor, who discharges the patient with minimal or no treatment at all (Lotem and Conforty, 1975). There is general agreement that it is of the utmost importance that wide excision to provide adequate drainage, with meticulous removal of
Engel et al.: Neurovascular Island Flap Reconstruchon
183
a
b
Fig. 2. Case 2. a, Final result, 10 months following transfer of the island flap from the long finger to the index. 6, Good range of motion of the index is demonstrated.
all necrotic and injured tissues, be done as soon as possible (Gelberman et al., 1975; Gillepsie et al., 1974; Schoo et al., 1980; Stark et al., 196 1). Operative treatment must be supported by antibiotics and anti-inflammatory therapy such as steroids and Oxyphenbutazone (Bottoms, 1962; Kaufman, 1968; Gillepsie et al., 1974; Gelberman et al., 1975; Phelbs et al., 1976; Schoo et al., 1980). Many cases will eventually require reconstructive procedures for loss of motion or sensation. Since the point ofentry of the noxious agent is the pulp ofthe finger in most cases, the adequate initial surgical treatment results in skin defects in this area. Satisfactory reconstruction should provide good quality skin plus sensation. This can be properly accomplished by using the neurovascular island flap, as first described by Esser (19 17) and Littler (1956). This technique was applied in both of our cases to rehabilitate the thumb (Case I) and index finger (Case 2). The good functional results encourage us to use it on similar cases in the future, especially when the thumb and index finger are involved.
REFERENCES
Bottoms R. W. A. (1962) A case of high pressure hydraulic tool injury to the hand, its treatment aided by dexamethazone and a plea for further trial of this substance. Med. J. Amt. 2,59 1. Dickson R. A. (1976) High pressure injection injuries of the hand. A clinical, chemical and histological study. Hand 8, 189. Esser J. F. (19 17) Island flaps. N. Y. Med. J. 106,264.
Gelberman R. H., Pesch J. L. and Urist J. M. (1975) High pressure injection injuries of the hand. J. Bone Joint Surg. 57A, 935. Gillepsie C. A., Rodeheaver G. T., Smith S. et al. (1974) Airless paint gun injuries: definition and enlargement. Am. J. Surg. 128, 138. Kaufman H. D. (1968) The clinicopathological correlation of high pressure injection injuries. Br. J. Surg. 55,214. Kaufman H. D. (1970) High pressure injection injurjes. The problems, pathogenesis and management. Hand 2,63. Littler J. W. (1956) Neurovascular pedicle transfer of tissue in reconstructive surgery of the hand. J. Bone Joint Surg. 38A, 9 17. Lotem M. and Conforty B. (1975) High pressure injection injuries ofthe hand. Harefiah 89,2 13.
184
Injury: the British Journal of Accident Surgery Vol. 1 ~/NO. 3
Phelbs D. B., Hastings H. and Boswick J. A. (1976) Systemic corticosteroid therapy for high pressure injection injuries ofthe hand. .I Trauma. 17,206. Rees C. E. (1937) Penetration of tissue by fuel oil under high pressure from diesel engine. JAMA 109, 866.
Schoo M. J., Scott F. A. and Boswick J. A. (1980) High pressure injection injuries of the hand. J. Trauma. 20,229.
Stark H. H., Wilson J. N. and Boyes J. H. (1961) Grease gun injuries of the hand. J. Bone Joint Surg. 4BA, 485.
Requests for reprints should be addressed IO: Dr Joel Engel, Hand Surgery Unit. The Chaim Sheba Medical Center, Tel Hashomer 5262 I, Israel.
181
Printedin Great Britain
Neurovascular island flap reconstruction following high pressure injection injuries of the hand Joel Engel and Eran Lin Hand Surgery Unit, The Chaim Sheba Medical Center, Tel Hashomer, Israel
Haggai Tsur Department of Plastic Surgery, Sackler School of Medicine, Tel A viv University, Israel
Summary
Adequate, satisfactory treatment of high pressure paint or grease injection of the hand invariably requires wide wound excision. This results quite ofien in a mutilated, disabled digit or hand, with loss of soft tissue and sensation. We report two such cases, each with a neurovascular island flap used in order to restore
adequate soft tissue and sensation. INTRODUCTION
SINCEthe first report of a high pressure injection injury of the hand by Rees in 1937, about 130 additional cases have been reported in Englishlanguage medical literature (Schoo et al., 1980). All papers emphasize the importance of early and adequate drainage and of extensive wound excision but there are few reviews of the final functional results. In the cases reported here, the patients required a number of operations in order to salvage the injured finger. After recovery from the initial procedures, both were left with disability due to loss of soft tissue and sensation. Reconstruction was then performed with a neurovascular island flap. To our knowledge, these are the first two such cases of high pressure injection injuries treated in such a manner to be reported in the medical literature.
CASE
REPORTS
Case 1
A 2%year-old man injured his right thumb with a high pressure paint gun. The pressure emitted by the gun was about 24 150 kPa. Two hours later the patient was seen in the emergency room by a house doctor who, being unfamiliar with high pressure injuries and unimpressed by the minimal clinical findings, treated the patient with tetanus toxoid and discharged him. The patient returned to the hospital the following day with severe swelling of the thumb and entire hand. A small black area, about 3 cm in diameter, was noticed on the pulp of the thumb. No signs of lymphangitis or lymphadenopathy were present. The patient was taken to the operating room and under intravenous block anaesthesia, a small palmar incision was made, which yielded large amounts of paint. Despite high doses of antibiotics, the infection failed to improve and 6 days later the hand was again explored. This time a wide exploration of the thumb and hand was performed with extensive removal of paint and necrotic soft tissue, including the flexor tendons and sheath. The wounds healed without complication, but the patient suffered from loss of sensation of the thumb. Ten months following the injury, reconstruction was performed by transferring an island flap from the ulnar aspect of the long finger to the tip of the thumb. Four months later, the patient returned to his original occupation as a driver. He demonstrated a full range of motion of the thumb, except for stiffness at the interphalangeal joint, and has good protective sensation of
182
tnjury: the Brrttsh Journal of Accident Surgery Vol. 1 ~/NO. 3
b Fig. I. Case 1. a, Final result, 1 year after transfer of island flap from the long finger to the thumb. (Flap and donor areas are circumscribed in black.) b. Close-up appearance of the thumb I year following transfer of the island flap. the thumb. He occasionally still confuses the thumb with the long finger. (See Fig. I .) Case 2 A 2 I -year-old man sustained a paint gun injury to the pulp of his index, of the left (non-dominant) hand. He was immediately admitted to the hospital and a few hours following the injury the index was explored under general anaesthesia through a zig-zag incision. The paint was found to penetrate from the point of entry at the tip of the finger to the level of the phalanx, involving the radial neurovascular bundle, but sparing the flexor tendon sheath. Extensive wound excision and irrigation were performed. All paint and damaged tissues were removed. Ten days later the patient was again operated on because of persistent infection. Following additional wound toilet, a fairly large area of skin loss was present on the volar aspect of the finger. A cross-finger flap was performed in order to cover the defect. Healing was uneventful. However, the anaesthetic flap handicapped the patient and 6 months later a neurovascular island flap was raised fromthe ulnar aspect of the long finger to replace the anaesthetic area of the index. Nine months following the injury, the patient returned to his normal occupation as a painter of automobiles, and has full sensation of the index, with good localization of touch as well as a good range of movement of the finger. (See Fig. 2.)
DISCUSSION High pressure paint and grease gun injuries of in modern the hand have become common
industry. Usually the material is injected into the index finger of the non-dominant hand (Gelberman et al., 1975; Dickson, 1976; Kaufman, 1968; Kaufman, 1970) at a pressure of 20 700-69 000 kPa. (Gillepsie et al., 1974; Schoo et al., 1980). The initial wound appears to the inexperienced observer to be a negligibly small injury; but within a few hours, the affected digit becomes swollen, severely painful, and starts to demonstrate early ischaemic changes (Rees, 1937; Gillepsie et al., 1974; Schoo et al., 1980). Lack of treatment, or inappropriate or inadequate care, will lead to necrosis and eventual amputation. Such a course of events is not an unusual occurrence when the patient, on being brought to an emergency room, is observed by an inexperienced young house doctor, who discharges the patient with minimal or no treatment at all (Lotem and Conforty, 1975). There is general agreement that it is of the utmost importance that wide excision to provide adequate drainage, with meticulous removal of
Engel et al.: Neurovascular Island Flap Reconstruchon
183
a
b
Fig. 2. Case 2. a, Final result, 10 months following transfer of the island flap from the long finger to the index. 6, Good range of motion of the index is demonstrated.
all necrotic and injured tissues, be done as soon as possible (Gelberman et al., 1975; Gillepsie et al., 1974; Schoo et al., 1980; Stark et al., 196 1). Operative treatment must be supported by antibiotics and anti-inflammatory therapy such as steroids and Oxyphenbutazone (Bottoms, 1962; Kaufman, 1968; Gillepsie et al., 1974; Gelberman et al., 1975; Phelbs et al., 1976; Schoo et al., 1980). Many cases will eventually require reconstructive procedures for loss of motion or sensation. Since the point ofentry of the noxious agent is the pulp ofthe finger in most cases, the adequate initial surgical treatment results in skin defects in this area. Satisfactory reconstruction should provide good quality skin plus sensation. This can be properly accomplished by using the neurovascular island flap, as first described by Esser (19 17) and Littler (1956). This technique was applied in both of our cases to rehabilitate the thumb (Case I) and index finger (Case 2). The good functional results encourage us to use it on similar cases in the future, especially when the thumb and index finger are involved.
REFERENCES
Bottoms R. W. A. (1962) A case of high pressure hydraulic tool injury to the hand, its treatment aided by dexamethazone and a plea for further trial of this substance. Med. J. Amt. 2,59 1. Dickson R. A. (1976) High pressure injection injuries of the hand. A clinical, chemical and histological study. Hand 8, 189. Esser J. F. (19 17) Island flaps. N. Y. Med. J. 106,264.
Gelberman R. H., Pesch J. L. and Urist J. M. (1975) High pressure injection injuries of the hand. J. Bone Joint Surg. 57A, 935. Gillepsie C. A., Rodeheaver G. T., Smith S. et al. (1974) Airless paint gun injuries: definition and enlargement. Am. J. Surg. 128, 138. Kaufman H. D. (1968) The clinicopathological correlation of high pressure injection injuries. Br. J. Surg. 55,214. Kaufman H. D. (1970) High pressure injection injurjes. The problems, pathogenesis and management. Hand 2,63. Littler J. W. (1956) Neurovascular pedicle transfer of tissue in reconstructive surgery of the hand. J. Bone Joint Surg. 38A, 9 17. Lotem M. and Conforty B. (1975) High pressure injection injuries ofthe hand. Harefiah 89,2 13.
184
Injury: the British Journal of Accident Surgery Vol. 1 ~/NO. 3
Phelbs D. B., Hastings H. and Boswick J. A. (1976) Systemic corticosteroid therapy for high pressure injection injuries ofthe hand. .I Trauma. 17,206. Rees C. E. (1937) Penetration of tissue by fuel oil under high pressure from diesel engine. JAMA 109, 866.
Schoo M. J., Scott F. A. and Boswick J. A. (1980) High pressure injection injuries of the hand. J. Trauma. 20,229.
Stark H. H., Wilson J. N. and Boyes J. H. (1961) Grease gun injuries of the hand. J. Bone Joint Surg. 4BA, 485.
Requests for reprints should be addressed IO: Dr Joel Engel, Hand Surgery Unit. The Chaim Sheba Medical Center, Tel Hashomer 5262 I, Israel.