Louisville = Manual for Hand Surgery-Outline

High Pressure Injection=20 Injuries

Historical=20 Aspects

Rees¹, in 1937, was the first to = describe a high=20 pressure injection injury and note the potential severity of the injury. = He=20 documented the clinical course of a 47 year old mechanic who had a = diesel fuel=20 injection injury. The patient initially presented with an apparently = innocuous=20 injury. He developed pain after a few hours and then developed a = systemic=20 response to the injury with lymphadenitis, leucocytosis and fever. His = finger=20 progressed to gangrene within a week and required ray amputation.

In 1941, Mason and Queen² described = three phases=20 that define the natural history of high pressure injection injuries = (early,=20 intermediate and late) and their description is still in use today.

The prognosis for these injuries was traditionally = so poor=20 that Kaufman³ in 1968 advocated amputation of the digit as = the=20 primary treatment.

History of=20 Illness

Many types of high pressure injection device are = now in=20 frequent use within an industrial setting. The minimum pressure required = to=20 breach intact human skin is 100psi or 7 x10⁵NM^{2 =} (7 bar)⁴ but pressures may exceed 2500 = bar (35500=20 lbs/in²). Most injuries are caused by grease guns, spray guns = and=20 diesel injectors but pneumatic hoses, plastic moulding or cement = injectors,=20 hydraulic lines, grease boxes, vaccination equipment and oil rig = drilling=20 devices can all produce these injuries. These devices are used, amongst = other=20 things, in painting, lubrication, cleaning, and mass farm immunization. = A=20 diverse spectrum of substances may be injected which vary in their local = and=20 systemic toxicity. These include paint, paint thinner, oil, diesel fuel, = grease,=20 hydraulic fluid, water, plastics, cement or biological vaccines.

Epidemiology

Schoo et al⁵ estimated the incidence of = high=20 pressure injection injuries to be 1 in 600 hand injuries attending an = emergency=20 department. There are no other estimates of its incidence in the = literature=20 although it is certainly an uncommon injury, albeit a serious one, = particularly=20 if its significance is initially unrecognised.

High pressure injection injuries predominantly = affect healthy=20 young men, since they are largely occupational injuries. It is usually = the non=20 dominant hand that is affected, with the index finger being the = commonest digit=20 affected. However, any area of the body can be affected and there have = been=20 reports of injuries to all regions of the body including the=20 scrotum⁶. Injuries to the digits tend to be serious as rapid = infusion=20 of a large volume of fluid into a small closed space leads to a rapid = increase=20 in interstitial pressure which may compromise the circulation to the = digit.

Grease guns are the most common type of equipment = involved in=20 these injuries and this may be because its users are less likely to be = skilled=20 than those who use other high pressure devices⁷.

Pathophysiology

Mason=20 and Queen divided the response to high pressure injection injury into = three=20 phases: the early, intermediate and late phases.

The=20 early response is of swelling, numbness and possible vascular = insufficiency due=20 to a combination of mechanical and chemical factors that may act=20 synergistically. In injuries producing a greater inflammatory response, = such as=20 paint thinner injuries, chemical inflammation is more likely to be = causative of=20 vascular compromise than the mechanical effect. In other injuries the=20 predominant factor is uncertain. The volume of the injected substance = itself=20 acts together with the local inflammatory response to raise the = interstitial=20 pressure. This may result in vascular occlusion either as a direct = effect of the=20 fluid volatising or as a result of venous or arterial compression.=20

Some=20 materials that produce local tissue destruction and necrosis may do so = by lipid=20 dissolution or by protein coagulation. Dickson⁸=20 suggested that in paint thinner injuries, the severe chemical = inflammation was=20 secondary to the alkyl benzines in white spirit. Superadded infection = might=20 further compromise tissue viability and extend the zone of tissue = necrosis and=20 gangrene.

In=20 the intermediate phase, there is the formation of foreign body = granulomata or=20 oleomata. This was first described by Hesse=20 in 1925⁹=20 who noted it in Russian recruits who injected themselves subcutaneously = with=20 grease to try to avoid national service. These are nodular tumours which = are the=20 result of a foreign body reaction to the injected material. Widespread = vessel=20 thrombosis occurs with an inflammatory reaction in the adventitia and = thrombosis=20 of the vasa vasorum and venae comitantes. This produces coagulative = necrosis of=20 the skin and subcutaneous tissue. Fat is lost from fat locules. Damage = to the=20 tendon sheath and perineural fibrosis results in late fibrosis and = contracture.=20 Oleomata may persist unchanged for years but the associated fibrosis may = affect=20 hand function.

The=20 late phase is rarely seen in developed countries. Here the skin over the = oleomata breaks down, producing persistent ulcers and sinuses which = discharge=20 grease and epithelial debris. They become secondarily infected and so = increase=20 inflammatory changes in the skin. There is a theoretical risk of = malignant=20 change in these longstanding sinuses.

Presentation

History=20

The=20 history should alert the clinician to the severity of the injury. The = patient=20 may either be aware himself of the severity of the injury or may have = been sent=20 to the emergency room by his employer who should have operating = instructions for=20 the equipment being used and guidelines as to when to seek attention.=20 Unfortunately, the clinician who is unaware of the potential = consequences of=20 these injuries may underestimate them and dismiss them as=20 trivial.

Taking=20 an adequate history of the pressure at which the equipment was = operating, the=20 time of the injury and the volume and nature of the material it = contained will=20 provide the diagnosis and suggest the likely prognosis.=20

Presenting=20 complaints

The patient may present without any symptoms since = pain is=20 not always initially present. A few hours after the injury, there is = increasing=20 pain and the patient may complain of some numbness and discoloration. =

Mechanism = of=20 Injury

Many studies suggest that inexperience in operating = the=20 equipment is a factor. Kaufman³ found that most of the = injuries were=20 in workers who had operated this equipment for less than six months = although=20 they may have operated similar low pressure equipment where testing the = nozzle=20 on the end of the finger was safe. Typically injury occurs when the gun = is being=20 cleaned, the safety nozzle having been removed, or when tested after = reassembly=20 or after the nozzle jams.

Physical=20 Examination

Inspection

Early signs are minimal, usually only a puncture = wound at the=20 site where the skin has been breached and oozing of the injected = substance from=20 the wound. There may be some local swelling. Occasionally the patient = may=20 present early with a digit which is pale, cool and numb showing obvious = vascular=20 compromise =96 these injuries do poorly even when appropriately treated. = A digital=20 Allen=92s test may demonstrate digital artery thrombosis but this is = unnecessary,=20 and it may be inadvisable to perform this test in this situation. =

Fig 1(a). Innocuous appearing entry wound with = seepage after=20 high pressure paint injection.

Fig 1(b) Minor local swelling with few other = signs

If the pain appears disproportionate to that = expected of the=20 injury, clinical evidence of raised compartment pressures should be = sought. If a=20 compartment syndrome is present, pain will be worsened by passively = stretching=20 of the muscles in that compartment. Test the anterior forearm = compartment by=20 passive wrist and finger extension, the wrist extensors and = brachioradialis=20 muscle by passively flexing wrist in ulnar deviation, and the dorsal = forearm=20 compartment by simultaneous wrist and digital flexion. Within the hand, = test the=20 adductor, thenar, hypothenar, and dorsal and volar interossei = compartments and=20 examine for an acute carpal tunnel syndrome.

Later presentation may show greater swelling and = stiffness of=20 the digits or a bluish discoloration if the venous circulation is=20 compromised.

If the patient does not present for days or weeks, = there may=20 be gangrene present or a swollen, stiff digit with subcutaneous tumours, = ulceration or discharging sinuses present. If left unattended, the = sinuses=20 become secondarily infected increasing inflammatory changes and fibrosis = and=20 producing more stiffness. There is a theoretical risk of malignant = change, with=20 squamous cell carcinoma developing within the chronic ulcers.

Palpation

The digit may be tender to touch along the path of = the=20 injected material. Sensation may decrease with swelling so there may be = reduced=20 two=96point discrimination. Capillary refill will be brisk if there is = venous=20 compromise or slow or absent if there is arterial compromise. Where = large=20 amounts of air are injected, crepitus may be demonstrable.

Later the patient may show a low grade fever. = Systemic=20 symptoms are otherwise dependent on the substance injected, with acute = renal=20 failure being reported after injection of wax solvent and acute lead=20 intoxication after injection of lead-based paint.

Quantification

Assessment of the severity of the injury is from a=20 combination of history, physical and operative findings. The severity = depends on=20 the nature of the material concerned and its distribution. The nature of = the=20 material includes its toxicity, its viscosity and its volume. The = distribution=20 depends on the site of injection, depth of penetration, anatomical plane = in=20 which spread occurs and the ejection pressure. Some of these factors are = interdependent.

Toxicity of = Injected=20 Material

The=20 toxicity of the material is dependent on its chemical composition. Lipid = soluble=20 materials produce a greater inflammatory response and therefore, greater = tissue=20 destruction, than grease. They will cause lipid dissolution even when = not under=20 pressure.

Fig 2(a). Extent of proximal solvent spread after = high=20 pressure injection to index finger

Fig 2(b) Outcome of injury

Paint=20 solvents are more toxic than either paint or diesel fuel, resulting in=20 amputation in 80% of = cases in one=20 series⁵.=20 Paint is composed of solvents, vehicles and pigments and sometimes = bacterial=20 contaminants, all of which contribute to the inflammatory response and = tissue=20 destruction. Grease causes less destruction and has less severe = inflammatory=20 response so the risk of amputation in the same series was only 20%.=20

Fig 1(a). Exploration of grease high pressure = injection to=20 index finger

Fig 1(b) Appearance of finger at end of surgical=20 debridement

Water=20 and air injuries are usually relatively benign. Even so, water injection = injuries can mimic gunshot injuries in their tissue destruction and = produce a=20 compartment syndrome. Estimation of their severity should not be based = purely on=20 the appearance of the external wound. Bacterial, fungal or chemical = inoculation=20 (with sewage or oil lubricant) in water jet injuries may further = complicate the=20 clinical picture.

High=20 energy gas injection from firing handgun blank rounds at close range can = cause=20 serious injury and gas embolism and death have been = reported¹⁰.

Viscosity

The=20 more viscous the material, the less it will spread. Paint, therefore, = does not=20 disperse as far as paint solvents which, therefore, affect a greater = volume of=20 tissue¹¹.=20

Site

Once=20 the material is injected, it travels until it meets resistance.=20 Kaufman⁷=20 using injections into cadaver hands defined clearly the expected course = of the=20 material according to the site of injection. The bones, tendons and = flexor=20 sheath act as points of resistance which deflect the material causing it = to=20 spread superficially through the soft tissues³.=20 Deeper spread depends on the anatomical site of injection. If the site = of=20 penetration is at the interphalangeal joint crease where the flexor = sheath is=20 weak, the substance will travel within the sheath and may therefore = spread more=20 proximally directly into the palm or wrist. Spread within the sheath = does not=20 appear to affect the prognosis¹².=20 With pressures exceeding 5-10000 psi, the tendon sheath will always be = at risk=20 of penetration. The anatomical arrangement of radial and ulnar bursae = makes=20 proximal spread into the wrist more likely if the injection site is into = the=20 little finger or thumb.

Diagram=20 1. Simplification of flexor sheath anatomy in the = hand

If=20 the puncture wound is eccentric, the dorsal surface of the digit is = likely to be=20 extensively involved. Material injected into the thenar or hypothenar = spaces is=20 likely to remain these compartments but may involve the intrinsic = muscles. In=20 the experimental situation, injection into the mid palmar space failed = to show=20 extension proximally into the wrist but extension to the dorsum did=20 occur⁷.

Injection=20 distally in the digits carries a worse prognosis, possibly related to = the=20 smaller volume of the digits and their lack of distensibility producing = a=20 greater rise in interstitial pressure¹³.=20 Kaufmann equated the amount of energy produced in a grease gun injury to = a digit=20 to a 1000kg weight falling from a height of 25cm. The velocity of the = jet of=20 material emitted may be up to 1550mph (2500km/hr) and the theoretical = kinetic=20 energy dissipated on impact may be calculated from the formula,=20 KE=3D1/2mv². Therefore, the digits, having a smaller mass = will have a=20 greater amount of kinetic energy to absorb and will hence suffer a worse = injury=20 than more proximal parts.

Ejection=20 pressure

Grease=20 guns produce pressures of 350-700 bar. Spray guns, that are used in the=20 application of paint, lacquer, semifluid cement, hydraulic fluids and = solvents=20 (paint thinner, turpentine or gasoline), operate in the range of 200-500 = bar and=20 diesel fuel injectors from 140-400 bar. Water guns operate between = 400-550=20 bar¹⁴=20 .

Volume

The=20 volume tolerated at different sites of injection is variable. The digits = can=20 only tolerate 1cc whilst the palm may tolerate more than = 5cc³.=20 Chicken vaccine injury, despite being in an oil-based carrier, does not = appear=20 as dangerous as pig vaccine perhaps due to their different respective = volumes=20 (0.2cc versus 2cc)^=
15.=20 A greater volume at the same site is related to poorer functional=20 results¹⁶.

Investigations

Laboratory

After a few hours and particularly with the = injection of oil=20 based substances, a leucocytosis may develop.

Sometimes=20 laboratory analysis of the fluid may help in gauging prognosis for = recovery or=20 bacteriology in assessing likely infecting = organisms.

X-rays

Radiographs are not essential and often add little = to the=20 examination. Plain radiographs may give some idea of the degree of = dispersion of=20 the substance if it is radio-opaque or if they demonstrate subcutaneous=20 emphysema. This may assist in planning the operative approach. Serial=20 radiographs may be performed intraoperatively to ensure removal of all = of the=20 injected material.

Fig 4. Lateral radiograph showing extent of = proximal spread=20 of radio-opaque paint in digit

Classification

The only classification used is that of early, = intermediate=20 and late stages of the disease as described by Mason and = Queen².=20 Classifying these injuries in relation to the substance injected would = be=20 reasonable for the purposes of both treatment and prognosis. The most = obvious=20 grouping would be for oil based substances, solvents and paints to be = grouped=20 together, all requiring aggressive debridement and medical management, = grease=20 injuries to form an intermediate group, all requiring aggressive = debridement but=20 not necessarily requiring antibiotics, and water and air injection = injuries to=20 form a separate group which may be suitable for conservative management. = .=20

Treatment

Medications and doses

Anti tetanus toxoid should be administered if the = patient is=20 not covered but tetanus immunoglobulin is only rarely indicated.

A=20 course of antibiotics, usually a combination of a cephalosporin and an=20 aminoglycoside, is commonly given although the evidence for this is=20 poor¹⁷.=20 In an experimental model, all organic dyes and all solvents were = bacteriocidal,=20 as were some of the vehicles used in paint although the inorganic dyes = had no=20 antibacterial action¹⁸.=20 Those agents most likely to create a greater inflammatory response were = also=20 most likely to be bacteriocidal. This is weighed against the knowledge = that the=20 presence of a foreign material in a wound will impair the body=92s = ability to=20 resist infection and even sub-infective quantities of bacteria may = result in=20 frank infection, especially where there is any evidence of vascular=20 compromise.

Some=20 authors suggest the use of antiplatelet agents such as aspirin and low = molecular=20 weight Dextran to improve the microcirculation to the digit but this is = not=20 routine practice.

Non=20 steroidal anti-inflammatory drugs may have some effect at reducing the=20 inflammatory response but any effect is not dramatic³.

Whether=20 steroids are of any therapeutic benefit is disputed. There is evidence = of=20 benefit in animal models^18,13.=20 In vivo, some authors recommend their use routinely¹⁹=20 , others use them for all except grease gun injuries where there is = minimal=20 tissue extension¹²=20 and others consider them contraindicated due to their depression of the=20 leucocyte response²⁰=20 Regional local = anaesthetic blockade=20 may be employed to improve the microcirculation by producing peripheral=20 vasodilatation. Digital blocks should be avoided as they may compromise = the=20 microcirculation by increasing the interstitial=20 pressure.

Splints

Splintage is used to reduce joint contracture and = provide the=20 best position from which to mobilize. The splint needs to be forearm = based and=20 maintain the hand in an intrinsic plus position. Night splintage may = need to=20 continue for some months following surgery.

Physical Therapy

Hand therapy is required in all cases whether = treated=20 surgically or conservatively. Even those who present late and require = amputation=20 are likely to require help with mobilization of their hand, as they are=20 frequently left with residual stiffness in adjacent digits.

Conservative management

As a rule, these injuries require expeditious = surgical=20 intervention but there are instances where conservative management may = be=20 appropriate. The decision should be made on a case by case basis and = only by an=20 experienced hand surgeon.

Those=20 cases that may be able to be managed without surgical intervention are = those=20 where the material, site and findings are favourable²¹.=20 The few cases in the literature where chicken vaccine has been injected = show=20 that, although in an oil carrier, it is =20 usually well tolerated¹⁵.=20 Air and water injection injuries are also relatively = benign^22,23=20 and may be sometimes treated conservatively with elevation, splintage = with or=20 without antibiotics and steroids. Water gun injuries only need = decompression if=20 there are signs of a compartment syndrome^{14, =
24}.=20

Even=20 if a decision is made to treat conservatively, these patients still = require=20 admission, careful observation and follow- up. Their digits tend to = remain=20 swollen for some weeks and their hands may become extremely stiff.=20

Surgical management

Surgical exploration should be the mainstay of = management for=20 this condition and should occur with the same urgency as for a = compartment=20 syndrome. The procedure should be carried out in a properly equipped = operating=20 room under regional or general anaesthesia and with the use of an upper = arm=20 tourniquet. Use of the emergency room theatre under local anaesthesia is = inappropriate. The entry wound is excised. Surgical incisions to explore = proximally and distally need to be planned with broad based flaps whose=20 vascularity is reliant on the least affected side where possible. Most = authors,=20 including ourselves, use Brunner type incisions but some recommend the = mid=20 lateral approach. The skin flaps are raised at the subcutaneous level = and=20 exploration may need to be extended more proximally than initially=20 predicted. All areas = infiltrated by=20 injected material must be exposed, to decompress the affected tissue and = perform=20 extensive exploration. =

Fig 5(a)& 5(b). Appearance of white paint = injection=20 injury at surgical exploration of injury shown in Figs = 1(a)&(b).

Foreign material and all necrotic tissue must be = excised=20 whilst preserving the neurovascular bundles and the flexor tendon = pulleys.=20 Removal of all of the injected material is not always possible. The = tourniquet=20 should be released to check flap viability prior to closure. The wound = is=20 copiously irrigated with normal saline to help reduce fibrosis and = scarring.=20 This remains our practice despite experimental evidence tht in rabbits = this may=20 encourage septicaemia¹⁸.The wounds are either closed loosely = or left=20 open to heal by secondary intention or be closed later with delayed skin = graft=20 or flap cover. The hand = is=20 immobilized in a volar resting splint.

Fig 6. Wounds loosely closely to protect vital = underlying=20 structures. Primary closure should be avoided as this may compromise = digit=20 viability further.

After 48 hours, the dressing and drains are removed = and a=20 programmed whirlpool treatment and active mobilization is begun. The patient is encouraged to = stop=20 smoking. =

Surgical surprises

The unwary are especially likely to underestimate = both the=20 severity and the extent of this injury (see Fig 7. for the potential for = spread=20 in these injuries). The surgical approach should be planned so that = proximal=20 extension of the wound is simple.

Fig 7(a). Puncture entry wound on volar surface of = base of=20 middle finger

Fig 7(b) Planning of surgical approach to allow = extension of=20 initial incision whilst maintaining good flap vascularity

Fig 7(c) Loose wound closure at end of = debridement

Prognosis and=20 outcomes of surgery

Multiple=20 factors determine the outcome of these injuries. Death has been reported = after=20 abdominal high pressure water injuries that have caused caecal=20 perforation²⁵=20 and after air embolism from high pressure air injection¹⁰.=20 There is a morbidity whether or not the digit is = salvaged.

Digital=20 amputation rates in the literature vary from 16%²⁰=20 to 48%⁵. It is presumed that the = prognosis is=20 worsened if there is any delay to surgery. Several authors have = suggested a=20 lower morbidity if the time from injury to decompression is less than = ten=20 hours^26,27,17.=20 Others studies¹³=20 have been unable to confirm this and in some those reaching surgery = first=20 appeared more likely to end in amputation^28,12.=20 In Schoo=92s series, 16 out of 21 that were amputated, were debrided = within 24=20 hours of the injury and ten in less than six hours. This may be due to = the=20 greater severity of their injuries. The time factor may play less of a = role in=20 those injuries where chemically induced inflammation rather than = pressure is the=20 primary noxiant. =20

The=20 risk of amputation varies with the material injected with a much worse = prognosis=20 for paint and paint thinners than grease probably due to a direct toxic = effect=20 on the tissues^12,29.=20 Schoo et al⁵=20 demonstrated an 80% amputation rate with paint solvents compared to an = overall=20 amputation rate of 48% if all materials were included. Gelberman et=20 al¹³=20 had 83% amputation rate with paint injuries compared to 24% with other=20 materials.

The=20 higher the injection pressure of the appliance the more likely = amputation will=20 result. In the review by Schoo⁵,=20 all cases where the ejection pressure was >7000 psi (500 bar) = culminated in=20 amputation. This only consisted of three cases of the 127 reviewed so it = is=20 impossible to conclude that injuries at a specific pressure or greater = should=20 always be amputated. Patients who show evidence of initial vascular = compromise=20 are likely to result in amputation¹².=20 Pinto et al²⁰=20 had a high digit salvage rate which he attributed to timely aggressive=20 debridement, open wound packing and delayed primary closure rather than = an=20 attempt to close the wound primarily.

The=20 volume of injected substance may contribute to the risk of amputation = but this=20 is difficult to ascertain as only animal vaccines come in a set=20 volume²⁷.It=20 is believed that the greater volume of material injected, the worse the=20 prognosis but this is difficult to prove except in the case of animal = vaccines=20 where a set volume is given. Injuries to the digits where there is = little room=20 for dispersal do worse than more proximal injuries that can tolerate a = greater=20 volume of injected material.

Little=20 work has been done documenting the quality of function of the hand = following=20 digit salvage. In one series, 92% returned to work with 62% who were = considered=20 to have functional hands²⁰.=20 Where=20 the digit was salvaged, there was a correlation between the material = injected=20 and the time to return to work with grease gun injuries involving a = longer=20 rehabilitation period⁵.

Christodoulou²⁸,=20 in his study of fifteen patients an average of 73 months post injury, = found that=20 three of the six who had had amputations had changed occupation Only one of the nine with = salvaged digits=20 had altered his work. In comparison to the uninjured hand, grip strength = was=20 decreased by 15%, lateral key pinch by 23%, and chuck grip by 25%. = Dynamic=20 muscle power was reduced by 27%. Sensory evaluation, where it was = possible,=20 showed a decrease in sensibility with only one patient having normal = sensation.=20 Seven had diminished light touch, three had diminished protective = sensation and=20 one had loss of protective sensation.

Outcomes

Complications

Infection=20 may occur despite antibiotic treatment and particularly when necrotic = tissue is=20 present. It may act synergistically with other factors to increase the=20 likelihood of amputation or, if the digit is saved, to prolong swelling = and=20 stiffness and therefore, the period of rehabilitation. Most authors give = antibiotics routinely but reported infection rates vary from=20 11.5%¹³=20 to 60%²⁰.=20 This series had a low rate of digit amputation but in retaining digits = there may=20 have been more tissue with compromised vascularity which may have = contributed to=20 this high infection rate. Infections are commonly due to Staphylococcus=20 epidermidis or aureus, Pseudomonas sp. or are=20 polmicrobial.

Rehabilitation the=20 Kleinert way

Hand therapy

Hand therapy starts within 48 hours of surgical = debridement=20 and concentrates on wound care, oedema control and range of motion = exercises.=20 Splintage at night starts on the day of surgery and continues until the = patient=20 is healed with a good functioning hand and no contracture or until no = further=20 improvement is expected and the scars have matured.

Many of our cases are secondary or tertiary = referrals that=20 present late after multiple debridements and these cases require a long = period=20 of rehabilitation to achieve any useful function.

The=20 Future

Substances applied to help remove the injected = substance are=20 likely to cause further tissue damage and there have not been any new = advances=20 in producing a solvent that would not perpetuate the problem.

The best way of avoiding morbidity from these = injuries is=20 primary prevention by providing safer equipment and good education on = how to use=20 it, secondary prevention in educating potential users to seek immediate = advice=20 following an injury and tertiary prevention in educating doctors and = nurses to=20 recognize the potential severity of this injury and how to manage it.=20 Establishing better criteria for when primary amputation may be = appropriate=20 would help in avoiding the morbidity and prolonged therapy associated = with these=20 injuries after delayed amputation.

Web = Sites and URLs=20

www.med.ucalgary.ca/o= emweb/highpres

www.emedicine.com/em= erg/topic226.htm

www.rentajet.co.uk/injury.h= tm

References

Rees, C.E., (1937). Penetration of the tissues by fuel oil under = high=20 pressure from a diesel engine. JAMA, 109:866-867.=20
Mason, M.L. Queen, F.B. (1941) Q Bull N West Univ Med Sch 15:122.=20
Kaufmann, H.D. (1968). The clinicopathological correalation of = high=20 pressure injection injuries. Brit J=20 Surg, 55:5:214-218.=20
4. Scott, A.R. (1983) Occupational high pressure injection = injuries:=20 pathogenesis and prevention. J Soc=20 Occup Med 33:56.=20
Schoo, M.J., Scott, F.A., Boswick, J.A., (1980). High-pressure = injection=20 injuries of the hand. J. Trauma, 20(3):229-238.=20
Behar, T.A., Anderson, = E.E.,=20 Barwick, W.J., Mohler, J.L. (1993). Sclerosing lipogranulomatosis: a = case=20 report of scrotal injection of automobile transmission fluid and = literature=20 review of subcutaneous injection of oils. Plast Reconstr Surg 91(2):352-61.=20
Kaufmann, H.D. (1970).High pressure injection injuries, the = problems,=20 pathogenesis and management. Hand,=20 2: 63-73.=20
Dickson R.A., (1976). High-pressure injection injuries of the = hand. A=20 clinical, chemical and histological study. Hand, 8:189-193.=20
Hesse E. (1925) Die chirurgische und gerichtlichmedizinische = bedeutung der=20 k=FCnstlich hervogerufenen erkrank=FCngen. Arch Klin. Chir 136:277-291.=20
Kragh, J.F., Benfanti P, Erpelding J.M, (2003) Gas injection = injuries from=20 handgun blanks. http//dsa.cs.amedd.army.mil/journal/J9726.htm=20
Booth CM. High pressure paint gun injuries (1977). Brit Med J 2(6098):1333-5.=20
Lewis, H.G., Clarke, P., Kneafsey, B., Brennen, M.D., (1998). A = 10-year=20 review of high-pressure injection injuries to the hand. J.Hand Surg 23B: 4:479-481.=20
Gelberman, RH, Posch, JL, Jurist, JM. 1975. High-pressure = injection=20 injuries to the hand. J Bone Joint Surg 57A: 7:935-937.=20
Weltmer JB, Pack LL, 1988. High-pressure water injection injuries = to the=20 extremities. J Bone Joint = Surg 70A: 1221-1223.=20
Couzens, G., Burke, F.D. (1995). Veterinary high-pressure = injection=20 injuries with innoculations for larger animals. J. Hand Surg. 20B: 4:497-499.=20
Ober L, Lepage D, Jeunet D, Gerard F, Garbuio P, Tropet Y. Hand = injuries=20 resulting from high pressure injection: lesions specific to industrial = oil.=20 Chirurgie de la Main. 2002;21(6):343-9.=20
Pai CH, Wei,DC, Hou, SP, 1991. High-pressure = injection=20 injuries of the hand. J. = Trauma, 31:110-112.=20
Gillespie,=20 C.A., Rodeheaver, G.T., Smith S, = et al=20 (1974). Airless paint gun injuries: Definition and management. Am J Surg 128:383-391.=20
Phelps D.B., Hastings, = H.,=20 Boswick, J.A., (1981). Systemic corticosteroid therapy for high = pressure=20 injection injuries of the hand. J.Trauma, 17:206-210.=20
Pinto MR. Turkula-Pinto LD. Cooney WP. = Wood=20 MB. = Dobyns JH.=20 (1993) High-pressure injection injuries of the hand: review of 25 = patients=20 managed by open wound technique. J.Hand=20 Surg. 18A(1):125-30. =
Kendrick RW. Colville J. (1982) Conservative management of a high = pressure=20 injection injury to the hand. Hand.=20 14(2):159-61.=20
Klareskov, B, Gebuhr, P., Rordam, P. (1986) Compressed air = injuries of the=20 hand. J. Hand Surg. 11B:436-437.=20
Kon M. Sagi A. (1985) High-pressure water jet injury of the hand. = J.Hand Surg.10A(3):412-4.=20
Curka PA, Chisholm CD.(1989). High-pressure water injection injury = to the=20 hand. Am J Emerg Med, 7:165-167.=20
Neill, R.W.K., George, B. (1969) Penetrating intra-abdominal = injury caused=20 by high pressure water jet. Brit Med=20 J. 2:357-358.=20
Stark, HH, Ashworth CR., Boyes, JH. 1967. Paint gun injuries of = the hand.=20 J Bone Joint Surg 49A:637-647.=20
Neal NC. Burke FD. 1991 High-pressure injection injuries. Injury. 22(6):467-70.=20
Christodoulou L, Melikyan EY, Woodbridge S. 2001. = Functional=20 outcome of high pressure injection injuries of the hand. J Trauma, 50(4): 717-720.=20
Stark, HH, Ashworth CR., Boyes, JH. 1967. Paint gun injuries of = the hand.=20 J Bone Joint Surg 49A:637-647.=20