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no osseous pathology was detected on his initial
radiograph, the radiopaque appearance of the paint could
be clearly recognized [Figure 1a and b], demonstrating
the high viscosity of the injected material. When the
radiograph was evaluated carefully, the paint was noted
to have spread proximally through the flexor tendon
sheath [Figure 1a and b].

Despite conservative treatment, the pain did not
subside, and venous congestion of the finger increased
in Figure 2. The patient returned to the emergency
department on the following day at which time he was
referred to our department with the diagnosis of an a b
infection of the distal phalanx. His examination at that Figure 1: (a) Lateral radiographic view; (b) anteroposterior radiographic
time was remarkable for significant edema of the digit, view of the patient, the radiopaque appearance of the paint could be
with an elevated white blood cell count. The differential recognized clearly
diagnosis included felon and pyogenic tenosynovitis,
and the patient was admitted immediately and taken
to the operating room. Mid‑lateral incisions were made
with findings remarkable for an abscess with a foul odor
and tissue necrosis. The pulp was irrigated, dressed
and splinted. Cefazolin and gentamicin were ordered
for microbial coverage, and dextran 40 and enoxaparin
sodium were ordered for circulatory support.
The following day, there were still overt signs of
infection, and the patient underwent re‑operation. Palmar
Z‑incisions were made for exposure of the flexor tendon
sheaths, and repeat debridement was performed. The
paint was found at the level of the proximal phalanx. Both
neurodigital bundles and the flexor digitorumprofundus
tendon were noted to have sustained damage by lysis
secondary to the infection [Figure 3a]. The soft tissue Figure 2: Necrosis of the pulp at the time of referral to the plastic
and bone were debrided aggressively [Figure 3b], and the surgery clinic
deep tissue was sampled for microbiological studies. On
the 4th day of hospitalization, cultures revealed mixed
Gram‑negative bacteria with the growth of Citrobacter
freundii, Morganella morgani and Proteus vulgaris. The
Department of Infectious Diseases was consulted, and
ciprofloxacin and metronidazole were administered per
their recommendation. During his stay, the patient was
treated with daily povidone‑iodine finger baths, the
wound dressing was changed daily, and the extremity
was elevated continuously. The white blood cell count
returned to a normal range by the 10th postoperative day,
and the inflammation signs such as swelling and edema
subsided. The pulp defect was then reconstructed with a a b
cross‑finger flap [Figure 4].
Figure 3: (a) Preoperative view of the paint along the neurovascular
The fingers were attached for 10 days at which time bundles and flexor tendon sheats; (b) the view after debridement
the pedicle was divided. The patient was transferred
to physical therapy after recovering from surgery, interphalangeal (PIP) and distal interphalangeal (DIP) joints
and eventually returned to his occupation 2 months (10°‑15° at the PIP and 10° at the DIP).
after the first session of physical therapy. He was
evaluated 12 months postinjury with Semmes‑Weinstein DISCUSSION
monofilaments and two‑point discrimination tests for
sensation. According to these tests, the patient had normal High pressure paint gun injuries of the hand and fingers are
sensation (Semmes‑Weinstein: value 2.83, corresponding very rare, but can progress to amputation. The diagnosis is
to green color). Tactile sensation was considered to usually delayed secondary to the benign initial appearance
be good to moderate with two‑point discrimination at combined with a lack of appropriate clinical knowledge
6.5 mm. The patient had mild contractures at the proximal among physicians. Surgical intervention including aggressive

Plast Aesthet Res || Vol 2 || Issue 6 || Nov 12, 2015 351