A high-pressure injection injury may present as a puncture wound, usually to the hand or foot.15 High-pressure equipment is designed to force liquids such as paint, paint thinner, grease, oil, or diesel fuel through a small nozzle under high pressure—sometimes up to several thousand psi. If held against or close to the skin, the liquid stream coming out of the nozzle will be injected through the skin and deposited in the subcutaneous tissues. Pressure required to penetrate the skin is approximately 100 psi, which is easily achieved by this type of equipment. These injuries are severe owing to the intense inflammation incited by the injected liquid and the vascular compromise that develops from edema within these tight tissue compartments. The type, amount, and velocity of material injected will determine the degree of tissue inflammatory response, and this material often spreads widely along fascial planes.
Patients who present soon after injury typically have pain out of proportion to the appearance of the injection wound, and swelling is minimal. 15 Despite this innocuous appearance, potentially serious damage can develop. Neurovascular function should be carefully assessed. Pain control should be achieved with parenteral analgesics; digital blocks are contraindicated so as to avoid increases in tissue pressure with resultant further compromise in perfusion. The extremity should be elevated in order to reduce swelling. Parenteral antibiotics against the gram-positive skin flora ( Staphylococcus and Streptococcus) should be administered. Radiographs should be taken because some material may be radiopaque and may demonstrate the extent of subcutaneous spread from the injection site. An appropriate hand specialist should be consulted and early surgical debridement implemented for an optimal outcome. 16
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