Ortho Hors D'oeuvres (Answer):
To review, this is a 35 year-old right-hand dominant man presenting with laceration to distal aspect of middle finger of left hand while working on a construction site.
Questions and Answers:
1) What is the key finding on x-ray?
This x-ray demonstrates obvious subcutaneous air tracking on the volar aspect of the middle phalanx all the way to the base of the digit--very proximal to the externally viewed injury
2) How was this injury likely sustained?
The x-ray findings here are pathognemonic for high-pressure injection injuries. High-pressure injectors are common construction-site tools that are used for paint application and removal.
3) What are the key next steps in history collection, physical exam, and management?
Important to know what was in the high-pressure injector. If industrial paints or paint thinners were involved, this is a hand emergency and the patient must go to the operating room as soon as possible. Time course is also important to obtain. If the patient has injected a benign substance (air or water) this will help you decide on a reasonable duration of observation.
Check for tendon injuries. There have been case reports of tendon injuries in patients with high-pressure injection wounds. Check for involvement of both flexor digitorum profundus and flexor digitorum superficialis. Flexor digitorum superficialis curves around to the dorsal aspect of the distal interphalangeal digit and so performs flexion at the proximal interphalangeal joint and extension at the distal interphalangeal joint.
Place the patient in a sky hook.
Keep them NPO.
Start maintenence IV fluids.
Start them on some broad spectrum antibiotics.
Call your friendly hand surgeon to discuss the operating room versus in-hospital observation
Costas-Chavarri A, Turker T, Kutz JE. Flexor tendon lacerations due to high-pressure water injection injury: a case report. Hand (N Y). 2012 Mar;7(1)121-3.
Sampson CS. High-pressure water injection injury. Int J Emerg Med. 2008 June; 1(2):151-154
Snarski JT, Birkhahn RH. Non-operative management of a high-pressure water injection injury to the hand. CJEM. 2005 Mar;7(2):124-6.