Quick consultation: Symptoms: Laceration and swelling of the hands: News in emergency medicine

A 28-year-old, right-dominant man presented to the emergency department with a left middle finger laceration suffered while using a high-pressure paint sprayer about two hours before his arrival. He reported pain and swelling at the injury site and upstream of the palm. The high pressure sprayer contained a non-metallic water-based paint. He was seen in an emergency care center immediately after the incident, where he received a tetanus vaccine and a digital nerve block to control the pain.

His vital signs were within normal limits, and he had a 1 cm laceration on the palmar aspect of his middle finger extending over the proximal interphalangeal joint with white paint visualized in the wound bed. A moderate fusiform swelling of the middle finger was observed, and he exhibited some tenderness covering the flexor tendon of the palm. Flexion and extension were intact in all joints. He also had normal capillary filling in the nail bed, but the sensation was absent in the affected finger due to the nerve block. Plain x-rays of the hands showed no bone injuries.

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Diagnosis: high pressure injection injury

High pressure injection injury is a rare but serious diagnosis. Pressure vessels are used in industrial settings to inject or spray oil, grease, paint, solvent and water. Some devices can provide an injection force greater than 10,000 psi (about 1,000 times that which will break the skin). (Injury. 2007; 38[3]: 298.)

The injected substance will travel from the injection site along the path of least resistance, typically through the fascial planes and along the neurovascular bundles. The clinical syndrome is characterized initially by a harmless, apparently benign lesion, followed by a severe delayed inflammatory response, characterized by increased pain, marked swelling, compartment syndrome and possible necrosis. Patients may also have thermal or caustic injury depending on the substance involved.

Typically, the patient is a young male worker, and the injuries are usually in the non-dominant hand. (Orthop Clin North America. 2016; 47[3]: 617.) Because symptoms are progressive, patients may not present for several hours after injury. A focused history should include the exact time of injury, the substance injected, the force involved (if known), and any neurovascular symptoms such as numbness or paresthesia. Physical examination often shows a benign-appearing entrance sore, but may also reveal severe swelling, marked tenderness several inches around the wound, and, in severe or delayed cases, a pale hand or finger, cold or necrotic. The damage can extend as proximally as the forearm. A thorough neurovascular examination is essential.

Most cases require rapid surgical lavage and debridement. (J Main Surg Am. 2012; 37[11]: 2404.) Once the diagnosis is made, an orthopedic or hand surgeon should be consulted immediately and everything should be done to bring the patient to the operating room as delays increase the risk of superinfection, necrosis and amputation . (Orthop Clin North America. 2016; 47[3]: 617.) Diagnosis is clinical, but imaging may be useful in some cases; X-rays can show the spread of radiopaque substances, such as paint, while CT scans can reveal the extent of the inflammation.

Obtaining imaging should never delay the surgical consultation. Amputation of a limb is the most feared complication, and the risk of amputation increases with delays in surgical management, the higher volume of material injected and the causticity of the material injected. (Orthop Clin N Am. 2016; 47[3]: 617.) Beyond the emergency surgical visit, adjunctive treatments that should be given in the emergency department include broad-spectrum antibiotics, tetanus vaccination, parenteral pain relievers, and blood pressure elevation. member. Postoperatively, patients are likely to be admitted to an intensive care unit for frequent neurovascular checks.

Our patient received parenteral pain control and cephalexin in the emergency room, then rushed to the operating room with hand surgery for surgical decompression and paint washing. Surgeons found a large amount of paint in the neurovascular bundle and along but not in the flexor tendon sheath extending into the palm. The patient was then admitted for frequent neurovascular checks and wound management. He was discharged after five days in hospital and is seeing occupational therapy for range of motion therapy.

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Dr. Staris a third-year resident physician in emergency medicine at LAC + USC Medical Center. Follow him on twitter@alextsternum. Dr Burkholderis an assistant professor of clinical emergency medicine at the Keck School of Medicine at the University of Southern California. Follow him on twitter@tayburkholder. Read the Quick Consult columns onhttp://bit.ly/EMN-QuickConsult.