ACEP ID:

Toxicology

Painful Hand—Must Know Now Knowledge

Dr. Gordon Wu and Dr. Mark Su
The Ronald O. Perelman Department of Emergency Medicine
New York University School of Medicine

A 50-year-old left hand dominant painter presents to the emergency department for a complaint of epoxy paint injury to right hand while at work. The patient was using a high pressure paint gun when it slipped and the high pressure spray gun hit his own hand. The patient denies any pain, sensory loss, weakness or parasthesia. The patient states, “It’s just a small cut, doc, not a big deal.”

Hand1
Figure 1: Increased erythema and
purulent drainage from the wound
noted on patients return visit one
week after initial injury.

PMH: none
Surgery: none
Social Hx: denies cigarette smoking or ethanol use

Vital Signs: BP: 130/70 mmHg; Pulse: 60 beats/min; Resp:16 breaths/min; Temp: 98.6° F; Oxygen Sat: 100% (room air)

Hand Exam: two punctate 2mm puncture wounds over volar aspect between 2nd and 3rd MCP joints at level of A1 pulley. Radial pulse palpable. Sensation intact over median/ulnar/radial nerve distribution. Flexion and extension intact throughout all 5 digits. No extensor lag. AIN/PIN intact. All digits warm and well perfused with brisk capillary refill. Compartments of the digits and hand are soft, no pain with passive extension.

Imaging: Xray: infiltration of high intensity material around second MCP joint with some soft tissue swelling, no bony or ligamentous injury (see pictures)

Consultation: Hand Surgery

ED Course: After injection with 2% lidocaine locally, puncture wounds were explored locally and irrigated with normal saline. The patient was given a tetanus toxoid booster vaccination and discharged from the ED with a one week course of oral cephalexin. He was instructed to return in one week for a wound check. When the patient returned to the hospital, he complained of worsening pain over the injection site, and purulent drainage, erythema and induration. The patient was admitted to the hospital for operative debridement and IV antibiotics. The next day the patient went to the operating room whereby epoxy glue was found encasing the 2nd and 3rd neurovascular bundles. All visible epoxy was removed and the hand was irrigated with saline. The patient was discharged home the next day with a bulky dressing. Upon follow up 4 months later, patient was deemed to have an excellent outcome with little to no pain, full range of motion and excellent grip strength. No sensory loss. The patient continues to be employed as a painter.

 Hand2
Figure 2: Close up shot of the two
punctate lesions, this picture was taken one
week after the initial injury with concern
for cellulitis and soft tissue infection.

Discussion:  High pressure injection injuries of the hand are infrequently seen in the Emergency Department but their severity can often be underestimated by both physicians and patients. The patients generally do not complain of significant pain and the lesion itself is frequently painless and benign in appearance. However high compression injection of foreign matter into the hand can cause a multitude of severe effects, related to the both mechanical compression, as well as the chemical irritation and subsequent edema resulting from the bodies physiological response to foreign matter.

In regard to the mechanical pressure, injected fluid naturally travels to areas of low resistance. Consequently, high pressure injuries can preferentially infiltrate and spread along the neurovascular bundles, causing traumatic dissection and compression, effectively creating localized compartment syndrome and ischemia.

Subsequently, chemical damage from the fluid itself may occur. Many of the chemicals used in high pressure guns can cause tissue destruction and inflammation, leading to fibrosis and scar formation. Paints and solvents are cytolytic[4] oil-based paints cause intense inflammatory responses, while white-spirit based paints disintegrate cell membranes [4] In contrast, injections with water or air are more benign and generally have good outcomes.

Lastly, infection may occur following fibrosis and ischemia. Broad spectrum antibiotics aimed at gram positive and gram negative bacteria as well as tetanus toxoid are indicated [1].

Prognostic factors of high-pressure injection injuries include the site of injection, the volume of injection, the pressure of the gun, the nature of the injected fluid and lastly the time between injury and adequate treatment. One study of 14 patients with high pressure paint gun injuries to the hand showed that those who underwent surgical decompression within first 10 hours had a better outcomes than those with delayed intervention [3]. Without surgical treatment the amputation rate of these injuries is reported to be between 30-48% [2]

Surgical exploration under general anesthesia appears to be the best treatment for high-pressure injection hand injuries [5]. All injected material and necrotic tissue should be removed and saline irrigation performed in a timely manner. Despite immediate treatment outcomes may still be disappointing. In addition to the possible acute sequelae, long-term morbidity may include contracture, hyperesthesia, pain, and cold intolerance. Many are unable to return to their occupations as a result. Emergency physicians need to be aware of possible high-pressure injection injuries of the hand and should have a low threshold to request immediate consultation from a hand surgeon.

 Hand3                                 Hand4

Figure 3: Lateral x-ray film showing the deposited epoxy paint on the palm                 Figure 4: AP film of the hand showing the deposited paint

 

  1. High-pressure injection injuries of the hand. A review. Sirio CA, Smith JS Jr, Graham WP 3rd Am Surg. 1989 Dec; 55(12):714-8.[PubMed] [Ref list]
  2. High-pressure injection injuries to the upper extremity: a review of the literature. Hogan CJ, Ruland RT J Orthop Trauma. 2006 Jul; 20(7):503-11.[PubMed] [Ref list]
  3. Stark HH, Asworth CR, Boyes JH (1967) Paint gun injuries of the hand. J Bone Joint Surg Am 49:637–647 [PubMed] [Ref list]
  4. Davod Jafari, High-Pressure Injection Injuries to the Hand. Shafa Orthopedic Journal: November 2016, 3(4); e4143.Published Online: July 24, 2016
  5. Injection injuries: seemingly minor injuries with major consequences, HZ DailianaD KotsakiS VaritimidisS MokaM BakaroziK Oikonomou, and NK Malizos, Department of Orthopaedic Syrgery, University of Thessalia, Larissa, Greece, School of Health Sciences, University of Thessalia, 22 PMCID: PMC253297

 


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