J Plast Surg Hand Surg, 2012; Early Online: 1–3 © 2012 Informa Healthcare ISSN: 2000-656X print / 2000-6764 online DOI: 10.3109/2000656X.2012.718895 CASE REPORT Late presentation of a case of high pressure cement injection injury to the hand Hakan ¸ Sirino glu, Burak Ersoy & Mehmet Bayramiçli Department of Plastic and Reconstructive Surgery, Marmara University School of Medicine, Istanbul, Turkey Abstract High-pressure injection injuries to the upper extremity cause potentially severe complications that result in multiple operations, amputations, and permanent functional deficits. Early exploration and debridement are the mainstays of treatment for optimal functional recovery. We describe the late presentation of a high-pressure cement injection injury to the hand, its management, and long term course. Key Words: High pressure, injection injury, cement, late referral, claw deformity Introduction High-pressure injection injuries of the upper extremity are rarely encountered, and have potentially severe complications that result in multiple operations and permanent functional deficits [1]. This type of occupational injury is the result of injection of various substances including wax, grease, hydrau- lic oil, cement, paint, and solvents that are sprayed through high-pressure guns [2,3]. Since the first description in 1937 [3], the incidence of these injuries has increased progressively with the greater prevalence of high-pressure equipment. While a pressure of only 100 psi can break the skin [4], these high- pressure guns reach pressures of between 2000 and 12000 psi, and they can cause considerable injury without direct contact with the skin. Because of the progressive tissue damage that is caused by the kinetic force of the explosion, ischaemia, chemical inflam- mation, and secondary infection, a high pressure injection injury is a surgical emergency that requires prompt attention. The initial innocuous appearance of the wound is often the cause of inaction by many practitioners and delays referral to a hand surgeon [5]. Early exploration and debridement after emergency assessment are invaluable for optimal functional recovery. We describe a late presentation of a case of high-pressure cement injection into the hypothenar area of the hand, its management, and the long term course. Case report A 33-year-old right-handed man was admitted to our clinic 25 days after cement injection by an airless cement gun into the hypothenar area of his left hand. He was given antibiotics intravenously and tetanus vaccination at a local hospital, and the wound was followed up there with daily irrigation and dressings for two weeks with no surgical intervention. When his symptoms worsened with reduced range of movement he was referred to our centre. Physical examination showed a 4 cm long volar laceration on the hypothenar area and a second orifice of 1 cm in diameter on the wrist. He had loss of abduction and weakened active flexion, and loss of sensitivity of the fourth and fifth digits. Radiographs showed an irregular opacity along the ulnar side of the hand mostly superposed on the carpal bones (Figure 1a). The wound was explored under general anaesthesia with a tourniquet. The application of an Esmarch bandage was avoided in order to prevent further proximal mobilisation of the cement particles. Hydrocortisone was given intravenously to reduce the inflammatory response. The palmaris brevis, abductor, opponens and flexor digiti minimi muscles had been extensively damaged and were debrided in an attempt to remove all cement particles. The carpal tunnel was opened and the incision on the forearm extended approximately 20 cm proximally. As a result hardened cement particles were found to have spread proximally along the facial planes as far as the mid-forearm. Segments of the ulnar artery and nerve roughly 15 cm long were heavily infiltrated and replaced by cement (Figure 1b).The median nerve and the radial artery were intact. After removal of all obvious particles of cement and devita- lised tissue, the wound was irrigated several times and cultures were taken. The wound was sutured and a Penrose drain was placed into the palm. The patient was listed for delayed reconstruction of the defect in the ulnar nerve and related tendon transfers. During the second operation under general anaesthesia the residual cement particles were removed, and the proximal stump of the ulnar nerve and the distal end of its motor branch were found. Sensory branches were invisible in the heavily fibrotic tissues of the hypothenar area. A nerve graft was harvested from the ipsilateral sural nerve to reconstruct the motor branch of the ulnar nerve. After the interfascicular nerve grafting had been completed (Figure 1c), the MP joint was dynamically corrected and the claw deformity of the fourth and fifth digits were also resolved. Follow-up was uneventful and the patient continued his recovery with physiotherapy. Correspondence: Burak Ersoy, MD, Marmara Üniversitesi Hastanesi, Plastik ve Rekonstrüktif Cerrahi A.D. Tophanelio glu Cad. No: 13-15 81190, Altunizade, _ Istanbul, Türkiye. Tel: +90 533 2322682. Fax: +90 216 3267722. E-mail: bubu77@gmail.com (Accepted 8 November 2010) Journal of Plastic Surgery and Hand Surgery Downloaded from informahealthcare.com by Charlotta Eklund on 08/01/13 For personal use only.