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of the injected material. Reconstruction and skin repair
can be delayed until a secondary debridement 24‑48 h
later. Flaps may be utilized in reconstruction following
regression of the infection, depending on the condition of
the open wound. Although there is controversy regarding
their use, steroids may be administered to decrease
inflammation. Despite treating 15 patients with steroids,
Hogan and Rutland noted that 8 of these patients still
required amputation. [10]
The most significant prognostic factor in high pressure
gun injuries is early diagnosis with prompt notification of
a hand surgeon. The rate of amputation has been shown
to be lower in patients who received debridement of
necrotic tissues within the first six hours following injury
[9]
Figure 4: Final postoperative view of the patient after reconstruction (58% vs. 88%). On the other hand, the properties of the
with a cross‑finger flap injected material are also very important, as injuries with
organic solvents (thinner, gasoline, etc.) have a higher risk
debridement and decompression must be undertaken in of amputation than other materials. [10]
the first 6 h to decrease the risk of amputation. Despite
aggressive therapy, the risk of amputation ranges from In conclusion, high pressure gun injuries are rare but
22% to 48%. Local necrosis appearing after the first 6 h constitute a true surgical emergency of the hand. The
[6]
postinjury may be associated with infection and advancing emergency department staff must be educated about
necrosis which spreads proximally. [7‑9] such injuries to prevent a delay in diagnosis. As noted
above, the most important prognostic factor is aggressive
In their study, Hogan and Ruland defined the epidemiology debridement undertaken within the first six hours
of high pressure paint gun injuries. The majority of the following injury. For this reason, the hand surgeon
[10]
patients were men with a mean age of thirty‑five years. must be consulted, broad spectrum antibiotics must be
The index finger of the nondominant hand was the most administered promptly, and tissues must be debrided as
frequent injured digit. Tissue damage may be either chemical early as possible.
or mechanical in nature. In general, the injected material
creates a small open wound at the entrance point, with Financial support and sponsorship
the material passing through the tissue and neurovascular Nil.
structures until it faces resistance. This movement causes
traumatic dissection with pressure secondary to the Conflicts of interest
injected fluid potentially causing compartment syndrome. There are no conflicts of interest.
The process advances further with an increase in volume
secondary to edema and the inflammation. Because the REFERENCES
injected material itself may cause chemical damage, the
clinical condition can rapidly deteriorate. All of these 1. Best RR. An Anatomical and clinical study of infections of the hand. Ann Surg
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the susceptibility to infection. For this reason, a regimen 2. Ki V, Rotstein C. Bacterial skin and soft tissue infections in adults: a review
of their epidemiology, pathogenesis, diagnosis, treatment and site of care.
of broad spectrum antibiotics is recommended by most Can J Infect Dis Med Microbiol 2007;19:173‑84.
authors. In Hogan and Ruland’s study, the microbiological 3. Rigopoulos N, Dailiana ZH, Varitimidis S, Malizos KN. Closed‑space hand
culture was positive with mixed bacteria in forty‑two percent infections: diagnostic and treatment considerations. Orthoped Rev 2012;4:e19.
of the patients. Infection can develop even in patients 4. Clark DC. Common acute hand infections. Am Fam Physician 2003;68:2167‑76.
[10]
who receive antibiotic therapy. However, their study did not 5. Bach HG, Steffin B, Chhadia AM, Kovachevich R, Gonzalez MH.
Community‑associated methicillin‑resistant Staphylococcus aureus hand
show a statistically significant difference in amputation rates infections in an urban setting. J Hand Surg Am 2007;32:380‑3.
between culture positive and culture negative patients. [10] 6. Bekler H, Gokce A, Beyzadeoglu T, Parmaksizoglu F. The surgical
treatment and outcomes of high‑pressure injection injuries of the hand.
If the patient has been injected with a material other J Hand Surg Eur Vol 2007;32:394‑9.
than water or air, debridement must be undertaken 7. Smith GD. High pressure injection injuries. Trauma 2005;7:95‑103.
within the first 6 h. Local‑regional or general anesthesia 8. Öktem F, Öçgüder A, Altuntaş N, Bozkurt M, Tellioğlu AT. High pressure
should be administered because the proximal extent of paint gun injection injury of the hand: a case report. J Plast Reconstr Aesthet
the injury cannot be known with certainty preoperatively. Surg 2009;62:e157‑9.
Digital nerve blocks are not recommended given the risk 9. Amsdell SL, Hammert WC. High‑Pressure Injection Injuries in the hand:
current treatment concept. Plast Reconstr Surg 2013;132:e586‑91.
of increased compression at the fingers. The tourniquet 10. Hogan CJ, Ruland RT. High‑pressure injection injuries to the upper extremity:
should be applied cautiously to avoid proximal migration a review of the literature. J Orthop Trauma 2006;20:503‑11.

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