see also:

• plastic surgery

• high pressure fluids can cause initially innocuous injury but devastating delayed injuries

• most common in laborers in industry using high pressure sprays or hydraulics such as paint, automotive grease, solvents and diesel oil

• a fluid spray at over 100psi pressure is sufficient to pass through the skin
• many sprays are 3,000-10,000psi and the fluid is travelling at up to ~600kph and the force can be equivalent to a 1 ton press falling from 25cm
• the injection of fluid dissects the soft tissues along lines of least resistance (including along neurovascular bundles)
• injury can arise from:
  • direct pressure injury which may cause vascular occlusion and subsequent tissue necrosis
  • chemical irritation
  • secondary inflammatory response
  • secondary infection

• often have a benign looking entry wound which is initially relatively painless
• if the injury is substantive, there will be delayed onset of oedema, tense tissues, pallor and cold which may then result in necrosis

• Xray - may show extend of radio-opaque material
• otherwise it is clinical

• tetanus prophylaxis
• limb elevation
• parenteral antibiotics for gram-negative and gram-positive coverage
• monitor for compartment syndrome
• avoid digital blocks and ice to prevent decreased perfusion
• contact plastic surgery early as most cases need emergent surgical debridement to remove foreign bodies, irrigate and debride necrotic tissue (this may need to be repeated in 24-72hrs)
  • approx. half of “non-operative, conservatively managed” cases will need surgery ¹⁾
  • if surgery is delayed > 10hrs, rate of amputation increases
  • ~half of finger injuries will need amputation
  • amputation rates approach 50% with organic solvents, oil-based paint, paint thinner, diesel fuel, jet fuel, or oil