VAQ 6 Answer

This looks like a really simple photo, and a simple injury, but beneath that tiny puncture wound lies a serious set of potential complications, that could cost the patient their arm if not correctly managed.  High pressure injection injuries are high risk, and require careful assessment and urgent disposition to a surgeon who knows how to manage them.

This type of injury carries a 30-80% risk of amputation, depending on what’s been injected, and time to definitive surgical management.  Surgery within 6 hours has a better outcome, and paint, paint thinner, gasoline, oil, or jet fuel (organic solvents) carry the highest risk of amputation.

Reference 1
Reference 2
Reference 3

And in case we haven’t been clear enough about how serious this can be, check out this pamphlet from a mining company that outlines instructions for workers with high pressure injection injuries, complete with recommendations, pre-formatted doctors letters, and instructions from a senior Sydney Hand Surgeon!  Alright, enough with the serious stuff, now onto the answer!

In hindsight probably should have made part a 30% and part b 70%, but you get the idea…

Describe and Interpret:

Photo: Right and left thumbs, flexor aspects
Single puncture wound pulp of left thumb
Small amount of bleeding/bruising around wound:
NB: Often far more extenisve injury than apparent on surface
Left proximal thumb and pulp larger than right – indicates swelling due to injected water/air

Left thumb pink/appears well perfused.

Can’t see nail injury/more proximal structures which may be injured.

Conclusion: High pressure injection injury to pulp of left thumb causing marked swelling.  Finger appears well perfused.
NB
Surgical Emergency: Finger +/- limb threatening injury

Assessment:
Important:
Assessment should not delay URGENT plastics/hand-surgery referral

At high risk for complications:
Early:
Compartment syndrome/neurovascular compromise
Chemical injury
NB may affect hand/forearm due to pressure of injected fluid
Late:
Infection
Digit/limb ischemia, contracture, amputation

History:
Mechanism of injury
   Maximum pressure of hose/device (domestic vs industrial)
   “Cleanliness” of water:  ?dirt/grease/paint contamination – increased risk infection, harder to debride:
   Grease: risk of fibrosis
   Paint: risk of necrosis
Pain Score
   Out of proportion to injury may indicate early compartment syndrome (finger/hand/arm)
Fasting status (likely to need surgical management)
Tetanus status
Injury at home/work: ? workers compensation

Past Hx
   Diabetes: incr risk periph vasc disease/ischemic risk, infection risk

Medication
   Anticoagulants – may increase swelling risk

Allergies
   Antibiotics
   Opiate analgesics
   Anaesthetic reactions

Examination:
A/B/C/full vital signs
Focus on injured limb
Neurovascular exam of whole limb:
Looking for:
Ischemia:
   Decreased cap refill
   Cool finger   
Compartment syndrome
   Pain out of proportion to injury
   Pain on passive stretch of finger/forearm tendons
NB: Sensory and vascular changes = LATE signs of compartment syndrome
Assess for proximal extent of injury – check whole arm for: subcutaneous emphysema/swelling/tenderness

Investigation:
Management likely guided buy clinical findings
However:
Xray hand/thumb + forearm +/- proximal arm as indicated
To rule out:
  Fracture
  Gas in soft tissues
  Foreign material

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