Zusammenfassung
Die Schwere dieser Handverletzung wird oftmals unterschätzt und führt in sehr vielen
Fällen zu bleibenden Schäden, vor allem aber zu Funktionseinbußen der Hand. Art, Druck,
Volumen und Gewebstoxizität der injizierten Substanz bestimmen den Verlauf und letztendlich
auch das Ergebnis. Das Hauptproblem dieser Verletzung ist das toxische Ödem mit der
Gefahr der Ischämie und Entwicklung einer Gangrän, die zu einer Amputation zwingen
kann. Pathophysiologisch bestehen mehrere oft synchrone Angriffspunkte; neben einem
Tamponade-Effekt durch Druckerhöhung spielen Mikrothrombosen, Gefäßspasmen und ein
inflammatorisches Geschehen eine wesentliche Rolle, abgesehen von den Irritationen
chemischer Genese. Im zeitlichen Ablauf lassen sich fast immer drei Stadien beobachten.
Rasches Handeln, verbunden mit einer ausgedehnten Dekompression und radikalen Ausräumung
sämtlichen Fremdmaterials sowie nekrotischen Gewebes, verbessert die Prognose entscheidend.
Einer primär offenen Wundbehandlung mit geplanten Second-look-Eingriffen und wiederholtem,
sorgfältigem Débridement schließt sich in der Sekundärphase der sichere Wundverschluss,
vorzugsweise mittels Lappenplastiken, an. Rekonstruktive Eingriffe bleiben der Spätphase
vorbehalten.
Von 43 Patienten des eigenen Krankengutes der vergangenen 28 Jahre (1972 bis 2000)
heilten nur neun Patienten folgenlos aus; bei 12 Patienten (28 %) war eine Amputation
in unterschiedlichem Niveau erforderlich. Schmieröl und Farbe oder Farblösungsmittel
waren die am häufigsten injizierten Substanzen.
Summary
High-pressure injection injuries are rare and the extent of tissue damage is often
underestimated. They usually have devastating effects on tissues and result in poor
functional outcome of the involved hand. The severity of these injuries is related
to the nature, pressure, volume and toxicity of the injected substance. The major
problem of this injury is a toxic edema followed by ischemia, causing a gangrene of
the involved finger, which may require amputation. The pathogenesis is characterized
by different, but often synchronous onsets, leading to an apparent chain of events
that occur once the material has been injected. Increase of pressure within the closed
space leads to tamponade, intravascular thrombosis and spasm of vessels create circulatory
embarrassment, a chemical irritation provokes an acute inflammation. Three stages
of progress are described. Timing is an important factor influencing the results.
An early, wide decompression and aggressive debridement with complete removal of foreign
substances and necrosectomy is recommended in the acute stage and will improve prognosis
and outcome. Open wound treatment and second-look operations during the intermediate
stage are followed by secondary wound closure with local or free flaps, if necessary.
We emphasize the role of early active motion during this time. Reconstructive surgery
is reserved for the late stage.
43 patients were treated surgically in our department over the last 28 years (1972
to 2000). 12 of them (28 %) required amputation at different levels of the involved
finger. Only nine patients healed without any functional loss. Most frequent injuries
were of the paint or paint-solvent and grease-gun type.
Schlüsselwörter
Hochdruck-Einspritzverletzungen - Finger - Hand
Key words
High-pressure injection injury (HPII) - hand - finger
Literatur
- 1
Adams J P, Fee N, Kenmore P I.
Tear-gas injuries.
J Bone Joint Surg [Am].
1966;
48
436-442
- 2
Apfelberg D B, Lash H, Maser M R, Ringer J, Armbruster R H.
High-pressure silicone injection injury of the hand.
J Trauma.
1975;
15
922-925
- 3
Baker J M.
Molten plastic injuries of the hand.
Plast Reconstr Surg.
1955;
15
233-240
- 4
Bauer H P, Haas H G.
Spritzpistolenverletzungen an der Hand.
Tägl Prax.
1980;
21
73-80
- 5
Beguin J M, Poilvache G, van Meerbeeck J, de Coninck A.
Lésions de la main par injection sous haute pression.
Ann Chir Main.
1985;
4
37-42
- 6
Bell R C.
Grease-gun injuries.
Brit J Plast Surg.
1952;
5
138-145
- 7
Belsole R J, Nolan M, Eichberg R D.
Sandblasting injury of the hand.
J Hand Surg.
1982;
7
523-525
- 8
Brunner U, Egloff B.
Handverletzungen mit Spritzpistole.
Schweiz Med Wochenschr.
1966;
96
1087-1094
- 9 Buck-Gramcko D, Hoffmann R, Neumann R.
Hochdruckeinspritzverletzungen. Buck-Gramcko D, Hoffmann R, Neumann R Der handchirurgische Notfall (Bibliothek für
Handchirurgie). 2. Aufl. Stuttgart; Hippokrates 1989: 165-169
- 10
Caspi I, Lin E, Nerubay J, Ezra E, Horoszowski H.
Subcutaneous emphysema following high-pressure injection injury of inert gas.
J Trauma.
1987;
27
1305-1306
- 11
Couzens G, Burke F D.
Veterinary high pressure injection injuries with inoculations for larger animals.
J Hand Surg [Br].
1995;
20
497-499
- 12
Craig E V.
A new high-pressure injection injury of the hand.
J Hand Surg [Am].
1984;
9
240-242
- 13
Daum R G.
Spritzpistolenverletzungen der Hand.
Notfallmed.
1977;
3
18-23
- 14
Dickson R A.
High pressure injection injuries of the hand: A clinical, chemical and histological
study.
Hand.
1976;
8
189-193
- 15
Engel J, Lin E, Tsur H.
Neurovascular island flap reconstruction following high pressure injection injuries
of the hand.
Injury.
1981;
13
181-184
- 16
Flint M H.
Plastic injection moulding injury.
Brit J Plast Surg.
1966;
19
70-78
- 17
Gelberman R H, Posch J L, Jurist J M.
High-pressure injection injuries of the hand.
J Bone Joint Surg [Am].
1975;
57
935-937
- 18
Gillespie C A, Rodeheaver G T, Smith S, Edgerton M T, Edlich R F.
Airless paint gun injuries: Definition and management.
Am J Surg.
1974;
128
383-391
- 19
Harter B T, Harter K C.
High-pressure injection injuries.
Hand Clin.
1986;
2
547-552
- 20
Hayes C W, Pan H C.
High-pressure injection injuries to the hand.
South Med J.
1982;
75
1491-1498, 1516
- 21
Hentschel M.
Verletzungen der Hand durch Fettpressen und Spritzpistolen.
Handchirurgie.
1970;
2
171-174
- 22
Kaufman H D.
The clinicopathological correlation of high-pressure injection injuries.
Br J Surg.
1968;
55
214-218
- 23
Kaufman H D.
High pressure injection injuries, the problems, pathogenesis and management.
Hand.
1970;
2
63-73
- 24
Kaufman H D, Williams H O.
Systemic absorption from high-pressure spray-gun injuries.
Br J Surg.
1966;
53
57-58
- 25
Kendrick R W, Colville J.
Conservative management of a high pressure injection injury to the hand.
Hand.
1982;
14
159-161
- 26
Klareskov B, Gebuhr P, Rørdam P.
Compressed air injuries to the hand.
J Hand Surg [Br].
1986;
11
436-437
- 27
Kon M, Sagi A.
High-pressure water jet injury of the hand.
J Hand Surg [Am].
1985;
10
412-414
- 28
Larsen J M, Bindinger A, Sherman R, Kuschner S H.
Insecticide injection injuries to both hands: A case report.
J Hand Surg [Am].
1992;
17
1073-1075
- 29
Lehmköster A, Zellner P R.
Hochdruckeinspritzverletzungen der Hand.
Unfallchirurg.
1986;
89
62-67
- 30
Lewis R C.
High-compression injection injuries to the hand.
Emerg Med Clin North Am.
1985;
3
373-381
- 31
Lewis H G, Clarke P, Kneafsey B, Brennen M D.
A 10-year review of high-pressure injection injuries to the hand.
J Hand Surg [Br].
1998;
23
479-481
- 32
Lilis R, Greeen S M, Field J, Fischbein A.
Paint spray gun injury of the hand.
JAMA.
1981;
246
1233-1235
- 33
Moutet F, Lantuejoul J P, Guinard D, Gérard P.
Caractère d'urgence et de gravité des lésions dues aux injections à haute pression
au niveau de la main.
Ann Chir Main.
1991;
10
476-481
- 34
Neal N C, Burke F D.
High-pressure injection injuries.
Injury.
1991;
22
467-470
- 35
O'Reilly R J, Blatt G.
Accidental high-pressure injection-gun injuries of the hand.
J Trauma.
1975;
15
24-31
- 36
Pai C-H, Wei D-C, Hou S-P.
High-pressure injection injuries of the hand.
J Trauma.
1991;
31
110-112
- 37
Phelps D B, Hastings H, Boswick J A.
Systemic corticosteroid therapy for high-pressure injection injuries of the hand.
J Trauma.
1976;
17
206-210
- 38
Pinto M R, Turkula-Pinto L D, Cooney W P, Wood M B, Dobyns J H.
High-pressure injection injuries of the hand: Review of 25 patients managed by open
wound technique.
J Hand Surg [Am].
1993;
18
125-130
- 39
Ramos H, Posch J L, Lie K K.
High-pressure injection injuries of the hand.
Plast Reconstr Surg.
1970;
45
221-226
- 40
Rees C E.
Penetration of tissue by fuel oil under high pressure from Diesel engine.
JAMA.
1937;
109
866-867
- 41
Scharizer E.
Der Zeitfaktor bei der Behandlung von Spritzpistolenverletzungen.
Akt Traumatol.
1981;
11
84-86
- 42
Schoo M J, Scott F A, Boswick J A.
High-pressure injection injuries of the hand.
J Trauma.
1980;
20
229-238
- 43
Silsby J J.
Pressure gun injection injuries of the hand.
West J Med.
1976;
125
271-276
- 44
Sirio C A, Smith J S, Graham W P.
High-pressure injection injuries of the hand.
Am Surg.
1989;
55
714-718
- 45
Smoot E C, Robson M C.
Acute management of foreign body injuries of the hand.
Ann Emerg Med.
1983;
12
434-437
- 46
Stark H H, Ashworth C R, Boyes J H.
Paint-gun injuries of the hand.
J Bone Joint Surg [Am].
1967;
49
637-647
- 47
Stark H H, Wilson J N, Boyes J H.
Grease-gun injuries of the hand.
J Bone Joint Surg [Am].
1961;
43
485-491
- 48
Stepanuk M.
High-pressure injection injuries to the hand. Report of 18 Cases.
J Am Orthop Assoc.
1976;
75
739-747
- 49
Stoffelen D, De Smet L, Broos P LO.
Delayed diagnosis of high-pressure injection injuries to the finger.
Acta Orthop Belg.
1994;
60
332-333
- 50
Tanaka Y, Tajima S, Yamamoto Y, Matsumoto K, Ohta T, Yasuda T.
Successful reconstruction of a high-pressure injection injury of the hand using a
first web flap of the foot.
J Reconstr Microsurg.
1993;
9
55-59
- 51 Ulmer J W. Hochdruckinjektionsverletzungen der Hand. Über den Einfluß des Zeitintervalls
zwischen Unfallgeschehen und operativer Behandlung. Inaugural-Dissertation Hamburg. Im
Eigenverlag der Humboldt-Universität 1991
- 52
Vinogradov I.
Über Spätfolgen künstlicher Oleogranulome.
Langenbecks Arch Klin Chir.
1936;
187
69-78
- 53
Williams C S, Riordan D C.
High velocity injection injuries of the hand.
South Med J.
1974;
67
295-302
1 vormals: 200 bis 1200 at; 1 at = 1 kp/cm² (0,981 bar) = 100 000 Pa; 1 MPa = 1 000
000 Pa.
Dr. med. Georg Rappold
Unfallkrankenhaus Lorenz Böhler
Donaueschingenstraße 13
1200 Wien
Österreich
Email: georg.rappold@auva.sozvers.at
