A 27-year-old painter comes to the emergency department due to severe pain in his left hand. Towards the end of the workday yesterday, he was using an industrial sprayer to paint a deck when he accidentally placed his left index finger over the sprayer nozzle, injecting paint into the finger. The patient initially had only localized soreness in the finger, but he awoke in the middle of the night with severe pain. The patient has no chronic medical conditions, and immunizations including tetanus are up to date. Blood pressure is 144/86 mm Hg, pulse is 100/minute, respirations are 18/minute, and temperature is 37.3 C (99.1 F). On examination, the patient's left index finger, hand, and forearm are swollen. There is a 4 mm puncture wound on the flexor surface of the left index finger near the proximal interphalangeal joint. There is tenderness along the flexor surface of the entire digit, and passive extension of the index finger causes severe pain radiating up the arm. Capillary refill is

Question

A 27-year-old painter comes to the emergency department due to severe pain in his left hand.  Towards the end of the workday yesterday, he was using an industrial sprayer to paint a deck when he accidentally placed his left index finger over the sprayer nozzle, injecting paint into the finger.  The patient initially had only localized soreness in the finger, but he awoke in the middle of the night with severe pain.  The patient has no chronic medical conditions, and immunizations including tetanus are up to date.  Blood pressure is 144/86 mm Hg, pulse is 100/minute, respirations are 18/minute, and temperature is 37.3 C (99.1 F).  On examination, the patient's left index finger, hand, and forearm are swollen.  There is a 4 mm puncture wound on the flexor surface of the left index finger near the proximal interphalangeal joint.  There is tenderness along the flexor surface of the entire digit, and passive extension of the index finger causes severe pain radiating up the arm.  Capillary refill is <2 seconds in the hand and all digits.  Which of the following is the best next step in management of this patient's condition?

Quizplus · Accepted Answer

Explanation: This patient with a high-pressure injection injury to his finger is likely developing acute compartment syndrome. High-pressure injection injury occurs when a substance (eg, paint, solvent, grease) enters the human body under high pressure (eg, 3,000-10,000 psi). It usually results from inappropriate or accidental operation of high-pressure equipment (eg, industrial paint sprayer) and commonly affects the non-dominant hand. Initially, patients may have only mild soreness at the injection site and an innocuous appearing puncture wound, for which they do not seek medical treatment. However, unseen internal damage has often occurred because the injected substance, due to the high injection pressure, can travel far up the flexor tendon sheath, into the hand and forearm compartments (eg, the deep anterior compartment, which has the flexor digitorum profundus). Then, in addition to the direct mechanical trauma sustained during injection, secondary injury often occurs from the following: Chemical irritation and inflammation: many commonly injected substances are extremely cytotoxic and lead to extensive cellular necrosis, inflammation, and edema. Infection: bacterial inoculation of tissue during injection leads to infection, worsened by ongoing tissue necrosis and ischemia. As hours pass after the initial injury, the accumulating inflammation and edema finally result in signs and symptoms of compartment syndrome, such as severe pain and pain with passive stretch of the affected muscles (eg, via extension of the index finger). compartment syndrome Management includes intravenous antibiotics, tetanus prophylaxis, and surgical consultation for debridement of all injected material and decompression (ie, fasciotomy) of affected muscle compartments. To reduce the risk of amputation, surgical debridement and fasciotomy should be performed immediately, ideally within 6 hours of the injection injury (Choices C, E). (Choice A) Systemic thrombolysis is often used in the management of acute extremity ischemia due to vascular occlusion (eg, thromboembolism), which can result in acute compartment syndrome. However, it is not indicated in this patient with normal perfusion (eg, capillary refill <2 seconds) and compartment syndrome caused by the toxicity of the injected paint. (Choice D) Neutralizing agents are injected to treat some exposures to caustic substances (eg, calcium gluconate for hydrofluoric acid burns). However, local injection is contraindicated in the setting of high-pressure injection injury because it further raises the compartment pressure, potentially worsening tissue ischemia. Educational objective: High-pressure injection injury is a limb-threatening condition. The entrance wound may look deceptively benign, but the injected material can spread into the hand and forearm, leading to tissue ischemia, necrosis, and compartment syndrome. Given the high risk of amputation, surgical debridement and fasciotomy should be performed immediately. References: Injection injuries: seemingly minor injuries with major consequences (http://www.ncbi.nlm.nih.gov/pubmed/18923762) Management of High-Pressure Injection Hand Injuries: A Multicentric, Retrospective, Observational Study (http://www.ncbi.nlm.nih.gov/pubmed/31744068)

A 27-Year-Old Painter Comes to the Emergency Department Due to Severe