In 1937, Rees published a case of a high-pressure injection (HPI) injury to the finger. This injury involved diesel fuel. [1] Before Rees’s report, Hesse had described a similar injury in 1925. [2]
HPI injuries involving grease and paint are considered surgical emergencies, whereas HPI injuries with other substances require careful clinical evaluation, surgical intervention, or both. [3] Clean water and air injuries may result in good functional outcomes with simple monitoring and conservative management (see Treatment). Generally, surgeons should have a low threshold for surgical management of HPI injuries. [4] Portable Cup Warmer
For patient education materials, see the Hand, Wrist, Elbow, and Shoulder Center, as well as Finger Injuries, Hand Injuries, and Puncture Wound.
High-pressure guns emit jet streams at pressures of thousands of pounds per square inch (psi). At these extreme pressures, material is forced through the skin, where diffusion can occur along fascial planes, tendon sheaths, and neurovascular bundles. [5]
Various mechanisms can be adduced to explain the clinical picture of HPI injuries. Ischemia, necrosis from high-velocity mechanical impact, the direct toxic effect of the involved chemical, and infection play major roles in these types of injuries. [6, 7, 8, 9] Factors contributing to digital ischemia include massive vessel thrombosis from volatilization of the injected material, temporary vascular spasm as a response to trauma, venous outflow obstruction from tissue distention, and digital artery compression. [10] The volume of material injected into a closed space and the resultant edema can exacerbate ischemia. [11]
The chemical properties of the injected material have a considerable effect on clinical injury. With viscous substances, such as grease and oil-based compounds, dispersion is less marked than it is with more fluid materials. These substances tend not to penetrate the flexor sheath, resulting in infiltration of the surrounding neurovascular bundles. Low-viscosity solvents, such as paint thinners, may disperse more readily into the soft tissues. Injection pressure is also reported to be a factor in the extent of injury. [12]
It has been suggested that the predominant mechanism of tissue damage is chemical irritation and that this is more important than ischemia. Ramos et al concluded that an injection of isotonic sodium chloride solution under high pressure into tissue does not produce a significant inflammatory reaction. [9, 13] Clinically, Pai et al noted that injected water did not induce extensive soft-tissue destruction, even when the injury was treated conservatively. [14]
Paint thinners lead to more extensive damage and may cause lipid dissolution and destruction of tissues, even when not injected under high pressure. [7, 15] Also, paints and paint thinners produce the most severe inflammatory responses, leading to high amputation rates. [5, 16] Grease has been shown to be associated with oleogranulomata formation (a reaction to foreign bodies), fistula formation, fibrosis, and poor functional outcomes. [8, 15, 17] Joint contractures and ankylosis are also seen. [18]
Common substances involved in HPI injuries include the following [18, 19, 20] :
In a 1970 report, Kaufman compared the kinetic energy from a grease gun to a 1000-kg weight falling from a height of 25 cm. [6] Injuries with compressed air (at pressures of up to 50-300 psi) and high-pressure water injection (up to 6000-8000 psi) are also seen. [21, 22, 12, 23, 24, 25, 26] HPI injuries continue to be caused by an increasing number of substances, including paint, wax, molten metal, air, water, paint thinner, and other solvents. [27, 28]
Although more than 100 case reports of HPI injuries of the hand can be found in the literature, the incidence is difficult to assess. Nonetheless, a group from the University of Colorado described an estimated incidence of 1 in 600 hand injuries seen in their emergency department. [18] These numbers suggest that HPI injuries to the hand are relatively common, given the widespread use of pressure machinery.
HPI injuries often manifest as innocuous lesions on the fingertip of a patient's nondominant hand. Depending on the substance involved, these injuries may follow a benign clinical course (for air and clean water) or may be deceptively destructive and lead to soft-tissue necrosis and amputation (for grease and paint).
Proper triage and management of HPI injuries of the hand is imperative; the attending physician should recognize grease and paint injuries as surgical emergencies. A delay in treatment may result in inferior functional outcomes. [7, 29] In the digits, amputation rates are as high as 48%. [18, 7, 13]
Overall, HPI injuries result in significant impairment of function and reintegration into the work force, as well as aesthetic deformity. The most common long-term impairments include cold intolerance and hypersensitivity; however, grip strength, pinch, range of motion, and two-point discrimination are also affected. [30, 31, 32]
Rees CE. Penetration of tissue by fuel oil under high pressure from a diesel engine. JAMA. 1937. 109:866-7.
Hesse.The surgical and forensic medical significance of artificially caused diseases.Arch Klin Chir. 1925. 136:277-91.
Hadeed A, Anthony JH, Hoffler CE. Hand High Pressure Injury. Treasure Island, FL: StatPearls; 2022. [Full Text].
Cannon TA. High-pressure Injection Injuries of the Hand. Orthop Clin North Am. 2016 Jul. 47 (3):617-24. [QxMD MEDLINE Link].
Agha FP. High-pressure paint gun injuries of hand: clinical and roentgen aspects. N Y State J Med. 1978 Oct. 78 (12):1955-6. [QxMD MEDLINE Link].
Kaufman HD. High pressure injection injuries, the problems, pathogenesis and management. Hand. 1970 Mar. 2 (1):63-73. [QxMD MEDLINE Link].
Lewis HG, Clarke P, Kneafsey B, Brennen MD. A 10-year review of high-pressure injection injuries to the hand. J Hand Surg Br. 1998 Aug. 23 (4):479-81. [QxMD MEDLINE Link].
Dickson RA. High pressure injection injuries of the hand. A clinical, chemical and histological study. Hand. 1976 Jun. 8 (2):189-93. [QxMD MEDLINE Link].
Craig EV. A new high-pressure injection injury of the hand. J Hand Surg Am. 1984 Mar. 9 (2):240-2. [QxMD MEDLINE Link].
Sirio CA, Smith JS Jr, Graham WP 3rd. High-pressure injection injuries of the hand. A review. Am Surg. 1989 Dec. 55 (12):714-8. [QxMD MEDLINE Link].
Curka PA, Chisholm CD. High-pressure water injection injury to the hand. Am J Emerg Med. 1989 Mar. 7 (2):165-7. [QxMD MEDLINE Link].
Walker WA, Burns RP, Adams J Sr. High-pressure water injury: case report. J Trauma. 1989 Feb. 29 (2):258-60. [QxMD MEDLINE Link].
Ramos H, Posch JL, Lie KK. High-pressure injection injuries of the hand. Plast Reconstr Surg. 1970 Mar. 45 (3):221-6. [QxMD MEDLINE Link].
Pai CH, Wei DC, Hou SP. High-pressure injection injuries of the hand. J Trauma. 1991 Jan. 31 (1):110-2. [QxMD MEDLINE Link].
Vasilevski D, Noorbergen M, Depierreux M, Lafontaine M. High-pressure injection injuries to the hand. Am J Emerg Med. 2000 Nov. 18 (7):820-4. [QxMD MEDLINE Link].
Harter BT Jr, Harter KC. High-pressure injection injuries. Hand Clin. 1986 Aug. 2 (3):547-52. [QxMD MEDLINE Link].
Wheeless CR III. High pressure injection injuries in the hand. Wheeless' Textbook of Orthopaedics. Available at http://www.wheelessonline.com/ortho/high_pressure_injection_injuries_in_the_hand. 2023; Accessed: April 17, 2023.
Schoo MJ, Scott FA, Boswick JA Jr. High-pressure injection injuries of the hand. J Trauma. 1980 Mar. 20 (3):229-38. [QxMD MEDLINE Link].
Peters W. High-pressure injection injuries. Can J Surg. 1991 Oct. 34 (5):511-3. [QxMD MEDLINE Link].
Bandyopadhyay C, Mitra A, Harrison RJ. Ocular injury with high-pressure paint: a case report. Arch Environ Occup Health. 2009 Summer. 64 (2):135-6. [QxMD MEDLINE Link].
Klareskov B, Gebuhr P, Rørdam P. Compressed air injuries of the hand. J Hand Surg Br. 1986 Oct. 11 (3):436-7. [QxMD MEDLINE Link].
Weltmer JB Jr, Pack LL. High-pressure water-gun injection injuries to the extremities. A report of six cases. J Bone Joint Surg Am. 1988 Sep. 70 (8):1221-3. [QxMD MEDLINE Link].
Austin JC, Hankin FM. High-pressure water injection causing an isolated tendon laceration: a case report. Am J Orthop (Belle Mead NJ). 2007 Apr. 36 (4):213-4. [QxMD MEDLINE Link].
Sampson CS. High-pressure water injection injury. Int J Emerg Med. 2008 Jun. 1 (2):151-4. [QxMD MEDLINE Link]. [Full Text].
Connolly CM, Munro KJ, Hogg FJ, Munnoch DA. Water-power: high pressure water jets and devastating lower limb injury. J Plast Reconstr Aesthet Surg. 2010 Mar. 63 (3):e327-8. [QxMD MEDLINE Link].
Waibel BH, Schenarts PJ, Sagraves SG. High-pressure water jet injury to the neck and arm. Am Surg. 2009 Jan. 75 (1):90-2. [QxMD MEDLINE Link].
Gutowski KA, Chu J, Choi M, Friedman DW. High-pressure hand injection injuries caused by dry cleaning solvents: case reports, review of the literature, and treatment guidelines. Plast Reconstr Surg. 2003 Jan. 111 (1):174-7. [QxMD MEDLINE Link].
Loveday I. High-pressure injection injuries. Emerg Nurse. 2007 Nov. 15 (7):22-3. [QxMD MEDLINE Link].
Dailiana HZ, Kotsaki D, Varitimidis S, Moka S, Bakarozi M, Oikonomou K, et al.Injection injuries: seemingly minor injuries with major consequences.Hippocrates.2008 Jan.12(1):33-6[QxMD MEDLINE Link].[Full Text]
Wieder A, Lapid O, Plakht Y, Sagi A. Long-term follow-up of high-pressure injection injuries to the hand. Plast Reconstr Surg. 2006 Jan. 117 (1):186-9. [QxMD MEDLINE Link].
Bekler H, Gokce A, Beyzadeoglu T, Parmaksizoglu F. The surgical treatment and outcomes of high-pressure injection injuries of the hand. J Hand Surg Eur Vol. 2007 Aug. 32 (4):394-9. [QxMD MEDLINE Link].
Verhoeven N, Hierner R. High-pressure injection injury of the hand: an often underestimated trauma: case report with study of the literature. Strategies Trauma Limb Reconstr. 2008 Apr. 3 (1):27-33. [QxMD MEDLINE Link].
Schnall SB, Mirzayan R. High-pressure injection injuries to the hand. Hand Clin. 1999 May. 15 (2):245-8, viii. [QxMD MEDLINE Link].
Karlbauer A, Gasperschitz F. High-pressure injection injury: a hand-threatening emergency. J Emerg Med. 1987 Sep-Oct. 5 (5):375-9. [QxMD MEDLINE Link].
Kaufman HD, Williams HO. Systemic absorption from high-pressure spray-gun injuries. Br J Surg. 1966 Jan. 53 (1):57-8. [QxMD MEDLINE Link].
Christodoulou L, Melikyan EY, Woodbridge S, Burke FD. Functional outcome of high-pressure injection injuries of the hand. J Trauma. 2001 Apr. 50 (4):717-20. [QxMD MEDLINE Link].
Foresman-Capuzzi J, Tadduni GT, Callahan T. A 56-year-old man sustains high pressure injection trauma to his hand. J Emerg Nurs. 2006 Aug. 32 (4):310-2. [QxMD MEDLINE Link].
Temple CL, Richards RS, Dawson WB. Pneumomediastinum after injection injury to the hand. Ann Plast Surg. 2000 Jul. 45 (1):64-6. [QxMD MEDLINE Link].
Hogan CJ, Ruland RT. High-pressure injection injuries to the upper extremity: a review of the literature. J Orthop Trauma. 2006 Jul. 20 (7):503-11. [QxMD MEDLINE Link].
Thakore HK. Hand injury with paint-gun. J Hand Surg Br. 1985 Feb. 10 (1):124-6. [QxMD MEDLINE Link].
Kaufman HD. The anatomy of experimentally produced high-pressure injection injuries of the hand. Br J Surg. 1968 May. 55 (5):340-4. [QxMD MEDLINE Link].
Neubrech F, Radu CA, Pauli D, Bickert B, Kneser U, Harhaus L. [Functional outcome following high-pressure injection injuries of the hand].Handlebar Microwave Plastic Chir.2017 Aug.49(3):162–168.[QxMD MEDLINE Link].
Pistoia F, Sanguinetti S, Zaottini F, Picasso R, Macciò M, Martinoli C. High-pressure injection injury of the hand: Clinical usefulness of ultrasound as an early diagnostic tool. J Clin Ultrasound. 2023 Apr 6. [QxMD MEDLINE Link].
Amsdell SL, Hammert WC. High-pressure injection injuries in the hand: current treatment concepts. Plast Reconstr Surg. 2013 Oct. 132 (4):586e-591e. [QxMD MEDLINE Link].
Bean B, Cook S, Loeffler BJ, Gaston RG. High-Pressure Water Injection Injuries of the Hand May Not Be Trivial. Orthopedics. 2018 Mar 1. 41 (2):e245-e251. [QxMD MEDLINE Link].
Rodríguez-Villar S, Kennedy RC, Dall'Antonia M, Menichetti CP. Management of industrial high-pressure fluid injection injuries (IHPFII): the Water Jetting Association (WJA) experience with water driven injuries. Eur J Trauma Emerg Surg. 2019 Jun. 45 (3):507-515. [QxMD MEDLINE Link]. [Full Text].
Fialkov JA, Freiberg A. High pressure injection injuries: an overview. J Emerg Med. 1991 Sep-Oct. 9 (5):367-71. [QxMD MEDLINE Link].
Stark HH, Ashworth CR, Boyes JH. Paint-gun injuries of the hand. J Bone Joint Surg Am. 1967 Jun. 49 (4):637-47. [QxMD MEDLINE Link].
Temiz G, Şirinoğlu H, Güvercin E, Yeşiloğlu N, Bozkurt M, Eser C, et al. A useful option to obtain maximal foreign body removal and better prognosis in high pressure injection injuries: Negative pressure wound therapy with instillation. J Plast Reconstr Aesthet Surg. 2016 Apr. 69 (4):570-2. [QxMD MEDLINE Link].
Fujitani T, Zenke Y, Shinone M, Menuki K, Fukumoto K, Sakai A. Negative Pressure Wound Therapy with Surgical Gloves to Repair Soft Tissue Defects in Hands. J UOEH. 2015 Sep 1. 37 (3):185-90. [QxMD MEDLINE Link]. [Full Text].
Marinovic M, Bakota B, Spanjol J, Sosa I, Grzalja N, Gulan G, et al. High pressure injection injury of the foot: a role of negative pressure wound therapy. Injury. 2013 Sep. 44 Suppl 3:S7-10. [QxMD MEDLINE Link].
Lewis RC Jr. High-compression injection injuries to the hand. Emerg Med Clin North Am. 1985 May. 3 (2):373-81. [QxMD MEDLINE Link].
BOTTOMS RW. A case of high pressure hydraulic tool injury to the hand, its treatment aided by dexamethasone and a plea for further trial of this substance. Med J Aust. 1962 Oct 13. 49(2):591-2. [QxMD MEDLINE Link].
Chaput B, Nouaille de Gorce H, Courtade-Saïdi M, Apredoaei C, Rongières M, Chavoin JP, et al. [The role of a systematic second look at 48-72 hours in high-pressure injection injuries to the hand: a retrospective study]. Chir Main. 2012 Oct. 31 (5):250-5. [QxMD MEDLINE Link].
Jugpal S Arneja, MD, MBA, FRCSC Professor (Clinical), Division of Plastic Surgery, University of British Columbia Faculty of Medicine, Canada Jugpal S Arneja, MD, MBA, FRCSC is a member of the following medical societies: American Academy of Pediatrics, American Burn Association, American Cleft Palate-Craniofacial Association, American College of Surgeons, American Society of Maxillofacial Surgeons, American Society of Plastic Surgeons, Canadian Medical Association, Canadian Society of Plastic Surgeons, Royal College of Physicians and Surgeons of Canada Disclosure: Nothing to disclose.
William Rennie, MD, FRCSC Former Professor of Surgery, University of Manitoba Faculty of Medicine, Canada William Rennie, MD, FRCSC is a member of the following medical societies: Canadian Medical Association, Quebec Medical Association, Canadian Orthopaedic Association Disclosure: Nothing to disclose.
RB Turner, MD, FRCSC Assistant Professor, Section of Plastic Surgery, University of Manitoba RB Turner, MD, FRCSC is a member of the following medical societies: Canadian Medical Association, Canadian Society of Plastic Surgeons, Canadian Medical Protective Association Disclosure: Nothing to disclose.
W Reid Waters, MD, CM, FACS, FRCPSC Associate Professor of Surgery, University of Manitoba Faculty of Medicine; Former Head of Plastic Surgery Section, Winnipeg Regional Health Authority, Canada W Reid Waters, MD, CM, FACS, FRCPSC is a member of the following medical societies: American College of Surgeons, American Society of Plastic Surgeons, Canadian Medical Association, Canadian Society of Plastic Surgeons, International College of Surgeons, Royal College of Physicians and Surgeons of Canada Disclosure: Nothing to disclose.
Jonathan Toy, MD Resident, Department of Surgery, Division of Plastic Surgery, University of Alberta Faculty of Medicine and Dentistry Jonathan Toy, MD is a member of the following medical societies: Alberta Medical Association, American Society of Plastic Surgeons, Canadian Medical Association, Canadian Society of Plastic Surgeons Disclosure: Nothing to disclose.
Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference Disclosure: Received salary from Medscape for employment. for: Medscape.
Thomas R Hunt III, MD Professor and Chairman, Joseph Barnhart Department of Orthopedic Surgery, Baylor College of Medicine Thomas R Hunt III, MD is a member of the following medical societies: American Orthopaedic Association, American Orthopaedic Society for Sports Medicine, Southern Orthopaedic Association, AO Foundation, American Academy of Orthopaedic Surgeons, American Association for Hand Surgery, American Society for Surgery of the Hand, Mid-America Orthopaedic Association Disclosure: Received royalty from Tornier for independent contractor; Received ownership interest from Tornier for none; Received royalty from Lippincott for independent contractor.
Harris Gellman, MD Consulting Surgeon, Broward Hand Center; Voluntary Clinical Professor of Orthopedic Surgery and Plastic Surgery, Departments of Orthopedic Surgery and Surgery, University of Miami, Leonard M Miller School of Medicine; Clinical Professor of Surgery, Nova Southeastern School of Medicine Harris Gellman, MD is a member of the following medical societies: American Academy of Medical Acupuncture, American Academy of Orthopaedic Surgeons, American Orthopaedic Association, American Society for Surgery of the Hand, Arkansas Medical Society, Florida Medical Association, Florida Orthopaedic Society Disclosure: Nothing to disclose.
Injection Molding Design Rules Peter M Murray, MD Professor and Chair, Department of Orthopedic Surgery, Mayo Clinic College of Medicine; Director of Education, Mayo Foundation for Medical Education and Research, Jacksonville; Consultant, Department of Orthopedic Surgery, Mayo Clinic, Jacksonville; Consulting Staff, Nemours Children's Clinic and Wolfson's Children's Hospital Peter M Murray, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American Orthopaedic Association, American Society for Reconstructive Microsurgery, Orthopaedic Research Society, Society of Military Orthopaedic Surgeons, American Association for Hand Surgery, American Society for Surgery of the Hand, Florida Medical Association Disclosure: Nothing to disclose.