Abstract
Background:
High-pressure injection injuries to the hand have been reported in both the community and industrial setting with varying levels of severity. However, there are little epidemiologic data regarding the prevalence of pressure-injection injuries. The purpose of this study is thus to describe trends in emergency department (ED) encounters associated with pressure injection injuries, thereby informing potential investments in research and education for these injuries.
Methods:
The National Electronic Injury Surveillance System (NEISS), a nationally representative database of all ED encounters, was queried for all high-pressure injection injuries from 2012 to 2021. Patient demographic and injury data were collected and analyzed to describe trends in incidence, patient demographics, and sequelae of hand injury associated with an ED encounter for a pressure injection-related injury.
Results:
There were an estimated 15 307 (95% confidence interval: 15 051-15 562) high-pressure injection hand injuries from 2012 to 2021. Injuries were more frequent on weekends with the highest incidence on Sundays (18.9%) and Saturdays (18.0%) and during late spring and summer months (58.6%), with peak incidence occurring in May (16.8%). High-pressure paint injuries demonstrated a significantly higher rate of infection (23.7% of injuries) than pressure washer injuries (3.7%); however, pressure washer injuries were much more common overall (90% vs 10%).
Conclusion:
High-pressure injection injuries to the hand and upper extremity represent a particularly concerning injury mechanism. Prompt recognition and proper management are crucial for improving outcomes. People that utilize pressure washers for household projects should be aware of the risks associated with these machines and utilize proper safety techniques.
Keywords: hand injury, injection injury, pressure washer, pressure-injection, finger injury, paint injury, summer hand injury, high pressure injury, high pressure injury epidemiology
Background
High-pressure liquid-spraying machines are commonly utilized in both the industrial setting and in the community. However, accidents due to improper use or malfunctioning can lead to injuries of the face or extremity that can be quite severe. Case reports previously have described high-pressure water injection injuries occurring in all extremities.1 -3 In the industrial setting, these machines have many different applications, and the liquid that they project may contain dangerous substances ranging from contaminated water to petroleum-based products or heavy metals.4 -6 In the community, however, published case reports suggest that injuries are consistently related to water-based pressure washer devices, although no epidemiologic study has been conducted to date.2,3,7
High-pressure injection injuries range in severity based on the amount of pressure with which the substance is ejected and the presence of hazardous chemicals or contaminants which can either be directly toxic or serve as fomites for infection. Consumer pressurized devices, such as pressure washers, which can generate between 2000 and 3000 pounds per square inch (psi) of force, tend to cause less severe injuries. 8 Injuries caused by these consumer devices tend to be characterized by abrasions or lacerations and are less likely to result in severe complications due to lower pressures and the fact that the primary substance being injected in these cases is clean water or air.7,9 However, substances such as paint, hydraulic fluid, or grease can be directly toxic to cells and cause mores significant injury with more robust local inflammation. 10 In patients with clean air or water injected, nonoperative management is generally warranted, although all patients presenting with injection injuries should be monitored closely for compartment syndrome.9 -11 Industrial devices can generate significantly more force (up to 100 000 psi) and can cause catastrophic injuries requiring amputation.1,9,12,13 Severe injuries can present with what appears be a small puncture wound, often resulting in a delay of care. In these cases, the injected substance tends to follow neurovascular bundles, tendon sheaths, or other structures along the path of least resistance and can travel large distances causing devastating tissue damage.9,14 Treatment for this type of injury involves wide debridement and decompression as well as washing out any toxic materials; amputation may be necessary and occurs in anywhere between 35% and 80% of cases. 10
Despite the many reports about these injuries and their outcomes, there are minimal epidemiologic data in the literature regarding the national incidence of these injuries and any trends regarding frequency or injury pattern. Therefore, the purpose of this study is to describe the trends in incidence, patient demographics, and injury pattern in high-pressure injection injuries resulting in visits to the emergency department (ED) over the previous 10 years (2012-2021). We additionally seek to provide information regarding best practices for avoiding and managing these injuries.
Methods
The U.S. Consumer Product Safety Commission National Electronic Injury Surveillance System (NEISS) is a nationally representative sample of all ED encounters associated with a consumer product. The NEISS has been used extensively for examining injury trends and patterns associated with consumer products in the United States, including hand-related injuries.15 -17 To construct this database, each year, approximately 100 hospital EDs are sampled, including children’s hospitals. Sampling weights are provided with each case to estimate national incidence. Each case also contains a narrative of the event which can be used to elucidate data that would not otherwise be captured with coding provided by the NEISS. As a review of de-identified, publicly available data, this study was exempt from our institutional review board.
The NEISS was used to query all high-pressure liquid injection occurring between 2012 and 2021. Product codes 887 (“Powered painting equipment”) and 888 (“Sprayers, not elsewhere classified”) were utilized to capture all powered paint sprayer and pressure washer injuries, respectively. 18 Patient narrative texts were manually reviewed by the authors to isolate injuries directly resulting via high-pressure injection mechanisms to the hand.
Incident date, patient demographics, diagnosis, injury type, injury location, narrative description of incident, and disposition data were collected from incident ED encounters. Provided weights were used to estimate national incidence of injuries. Descriptive analyses were then performed to evaluate patterns of presentation, patient demographics, and injury characteristics. Using narrative descriptions, specific details about injury pattern such as specific location of hand injury (including specific digit when possible), laterality of injury, and complicating factors (e.g., infection on presentation) were also collected.
All national incidence estimates were calculated with the Complex Samples function of SPSS (IBM, Armonk, New York) to account for clustering and to produce 95% confidence intervals (CI) around estimates. Linear regression analysis was performed to describe change in incidence over time. For national estimates, nonoverlapping 95% CIs were used to determine significance.
Results
National Estimates of High-Pressure Injection Hand Injuries
There were an estimated 15 307 (95% CI: 15 051-15 562) high-pressure injection hand injuries from 2012 to 2021. The mean incidence rate was 1531 cases per year (95% CI: 945-2117). For context, distal radius fractures, the second most common type of fracture in the United States, have an estimated incidence of 643 000 per year. 19 Injuries to the hand comprised 31.2% of all high-pressure injuries over the last decade. There was a significantly higher rate of injury due to pressure washers (90.0%) versus paint sprayers (10.0%). The incidence of these injuries increased over time although not significantly (R = 0.409, R2= 0.167, P = .241; Figure 1). Injuries were more frequent on weekends with the highest incidence on Sundays (18.9%) and Saturdays (18.0%; Figure 2). The majority of injuries (58.6%) occurred during late spring and summer months, with peak incidence occurring in May (16.8%; Figure 3).
Figure 1.
Incidence of injuries for 10 years of data pulled for analysis, showing a trend toward increasing injuries over time, although not statistically significant (R = 0.409, R2= 0.167, P = .241).
Figure 2.
Incidence of injury as depicted by day of the week.
Frequency increased on weekends with the highest incidence on Sundays (18.9%) and Saturdays (18.0%).
Figure 3.
Incidence of injury as depicted by month of the year. Of all, 58.6% occurred during warmer months, with peak incidence occurring in May 16.8%.
Patient Characteristics Associated With Injury
Demographic characteristics of high-pressure hand injury patients are described. Men were more commonly injured (85.7%) than women (14.3%). The most common age demographic injured were 50- to 59-year-olds (21.5%), followed by 60- to 69-year-olds (19.8%), and 30- to 39-year-olds (18.5%). The least commonly injured groups were those younger than 10 years (0.5%) and those older than 80 years (1.5%). The most commonly injured patient subgroup were men of ages 50 to 59 years. Race data were available for 65.0% of patients: 87.7% of injured patients were white, 6.1% were black, 4.7% were Hispanic, 0.8% were American Indian/Native American, and 0.6% were Asian.
Injury Pattern and Location
The majority of injuries were lacerations (73% of total). Other common injuries included punctures (12%), contusion (10%), and avulsion injuries (4%). Nerve damage and amputation were both listed in less than 1% of all injuries. The majority of cases were discharged from the hospital (87.3%), with a considerable proportion requiring admission or observation (7.6%). Patient transfer to another institution occurred in 3.3% of all cases.
Finger injuries (59.7%) were more common than hand injuries (40.3% of all cases). Details on the specific location of injuries were available for only 38.8% of hand and finger injuries on review of the narrative (5945/15 306). The most common injury location was the index finger (28.6%), followed by the thumb (25.1%), middle (12.3%), and small fingers (11.5%). Injuries to the palm occurred in 4.3% of all hand-related injuries versus 4.1% to the dorsum of the hand (Table 1). Multiple digits were injured in 4.4% of all hand cases. There was a significant predominance of left-sided injuries (66.7%; Table 1). Bilateral injuries occurred in only 1.0% of cases.
Table 1.
Location of Injury.
| Estimate (95% CI) | Count | Percentage (%) | |
|---|---|---|---|
| Location on person (reported for all patients) | |||
| Hand | 6169 (5182-7156) | 125 | 40.3 |
| Fingers | 9137 (8141-10144) | 202 | 59.7 |
| Hand injury (reported for 5945 patients) | |||
| Thumb | 1492 (896-2088) | 28 | 25.1 |
| Index | 1703 (1067-2339) | 37 | 28.6 |
| Middle | 729 (308-1150) | 16 | 12.3 |
| Ring | 513 (151-875) | 10 | 8.6 |
| Small | 682 (252-1111) | 11 | 11.5 |
| Palm | 253 (12-495) | 6 | 4.3 |
| Multiple | 262 (17-508) | 6 | 4.4 |
| Dorsum | 243 (1-487) | 5 | 4.1 |
| First web space | 67 (1-199) | 1 | 1.1 |
| Handedness of injury (reported for 8319 patients) | |||
| Left | 5548 (4578-6518) | 111 | 66.7 |
| Right | 2692 (1921-3463) | 53 | 32.4 |
| Bilateral | 79 (1-235) | 1 | 1.0 |
Note. CI = confidence interval.
There were an estimated 867 cases of infection, present on admission (95% CI: 148-1585), most commonly due to cellulitis (76.0% of infections). Flexor tenosynovitis and abscess formation were seen in 0.4% and 0.1% of all injuries, respectively. High-pressure paint injuries demonstrated a significantly higher rate of infections (23.7% of injuries) than pressure washer injuries (3.7%). Flexor tenosynovitis was estimated in 4.4% of all paint-related injuries versus no documented cases in pressure washer injuries.
Discussion
Our data clearly illustrate the potential risks that high-pressure sprayers and washers pose to users. They confirm the widely held belief that high-pressure injection injuries result in a substantial number of ED visits each year, and the observed infection (5.66%) and admission rates (7.6%) support the notion that these injuries have potential for morbidity. Injuries occurred most often on weekends (Saturdays and Sundays) and were clustered predominantly in the late spring and summer (58.6%), with the largest number of injuries occurring during the month of May (16.8%). These numbers likely reflect the fact that the majority of injury presentations were due to pressure washers (90%), which are commonly used in the community for various cleaning purposes, and suggest that a large proportion of the injuries were the result of voluntary work around the home and not occupational injuries in an industrial setting. It is likely that homeowners preferentially perform exterior cleaning projects utilizing pressure washers in the warmer spring and summer months, leading to an increase in ED injury presentations.
In addition, our data clarify the populations most at risk for pressure-injection injuries. Males made up a significant proportion of the injuries (85.7%), with males between the ages of 50 and 59 years making up the single largest cohort of injury presentations (21.5%), followed by males in their sixties (19.8%). This male predominance in injuries is consistent with other literature describing pressure-injection injuries, 9 and the somewhat older age groups presenting with these injuries again potentially reflect the idea that these injuries are occurring in a domestic setting rather than industrial.
The fingers were the most common location of injury (59.7%), with the index finger being the most common specific site of injury (28.6%), followed by the thumb (25.1%). A significant majority of injuries occurred on the left side (66.7%), which was presumably the nondominant hand for many of the presenting patients. This is notable as it could indicate that patients are more likely to injure themselves when leaning against a surface or when using their nondominant hand to stabilize their spraying. Most of the injury presentations were classified as lacerations (73%), presumably due to the high-pressure spray severing the skin. While nerve damage and/or amputation were documented in less than 1% of the injuries, a substantial number of patients (7.6%) required admission or observation, and 3.3% were transferred to another institution, likely because of the significance of their injuries. Injuries resulting from high-pressure paint sprayers had a significantly greater likelihood than pressure washers of causing infection, with 23.7% of paint-sprayer injuries resulting in infection compared with only 3.7% of pressure washer injuries resulting in infection.
Our data suggest that a heightened focus be placed on awareness and prevention of pressure washer injuries. This potential for severe morbidity is often masked by a relatively inconspicuous appearance of the external wound.20,21 Patients with high-pressure injuries often present with what appear to be small puncture wounds, yet this external appearance may belie the extent of the underlying tissue damage and could potentially cause care providers to misjudge the severity of the injury. 21 The high pressure of fluid from the washer or sprayer often results in significant soft-tissue injury underneath the skin, which can be compounded by chemical injury from the injection of the washer or sprayer fluid. Hours after presenting with a seemingly minor injury, almost all patients develop compartment syndrome, which can result in loss of the affected limb if not treated urgently. 21 The injection injury may also lead to significant bacterial infection of the affected tissue. 22 This potential for soft-tissue injury is not limited to the upper extremities; however, high-pressure injection injuries can cause significant damage to any part of the body. Any device that produces ejection pressures in excess of 100 psi has the ability to break the skin and cause significant tissue damage.20,21
When an injury does occur, early recognition and treatment are critical to successful management.20,21,23 Prompt presentation to an ED and consultation with a hand surgery consultant should be considered for these injuries with any material other than water or in the setting of significant swelling or volume injected. Emergency clinicians should suspect significant soft-tissue damage when patients present with high-pressure injection injuries and should administer antibiotics and a tetanus vaccination depending on the patient’s vaccination status. 20 Imaging may help demonstrate the extent of the underlying injury and assist with surgical planning utilizing plain film radiography in the setting of injection of a radiopaque material. 23 Both surgeons and emergency care providers should also be aware of the potential for compartment syndrome with high volumes of injection and/or swelling.21,22
Interestingly, in this sample, there were no incidents of injection with devices other than a paint sprayer or pressure washer, despite a relatively large sample size. Tools utilized for cleaning industrial equipment or automotive parts may be less utilized in the community, which possibly signals an increased awareness of safety around these devices. Furthermore, there was a less than 1% rate of amputation, despite a relatively high rate of injury from paint sprayers, which classically have been associated with a higher rate of amputation. This may result from a trend toward latex-based rather than oil-based paint usage in the community, which is less proinflammatory to the tissue, and therefore may result in lower rates of amputation and other severe sequelae. 10 Unfortunately, data regarding paint type were not readily available in the majority of cases, but there does seem to be a trend in the community toward latex-based paint, due to application characteristics, cost, and environmental concerns. 10
Limitations
One limitation to the current study is that it likely underestimates the true national incidence of high-pressure injection injuries, as the NEISS data only take into account patients that present to the ED for their injuries. It is possible that many patients self-treat or present to non-ED providers for their injuries, such as orthopedic surgeons, urgent care clinic providers, or primary care physicians. Patients with less-significant injuries or with difficulty accessing medical care may not seek medical attention at all and are therefore not captured in our dataset. In addition, patient narratives within the NEISS database are limited to initial ED encounters, and the keywords are entered into the patient narrative by NEISS coders. If these coders did not classify an injury with the product codes included in our search, the injury would not be captured in our data. Prior to 2018, only 1 body part was included in each encounter listed in the NEISS. The addition of a second body part variable after 2018 potentially increases the specificity of data regarding injury location for each encounter and could impact our results. Specific injury location was only available in 38.8% of patient narratives, and incidences of tendon, nerve, or vascular injury or infection may not be included in initial ED encounter narratives and are thus likely underestimated in the current study. The location of the hospitals sampled for the NEISS data could also influence our data, as homeowners in certain areas of the country may be less likely to use pressure washers for cleaning their home or property due to the regional climate or geography. Given the nature the NEISS data, it was not possible in all cases to determine the type of solution involved in injection injuries, which could affect the observed injury statistics. Finally, while the NEISS database does provide some data about disposition from the ED, it is not designed to track long-term follow-up and subsequent complications.
Conclusion
High-pressure injection injuries to the hand and upper extremity represent a relatively common and particularly concerning injury mechanism. Prompt recognition and proper management are crucial for minimizing morbidity and improving outcomes. People that work with or utilize pressure washers for household projects should be aware of the risks associated with these machines and utilize proper safety techniques to mitigate these risks. Further research is needed to improve our understanding of the optimal treatment approaches for high-pressure injection injuries and to develop new strategies for preventing these injuries.
Footnotes
Ethical Approval: This study was actually exempt from IRB board approval.
Statement of Human and Animal Rights: Due to the retrospective nature of the study and publicly available data, this study was deemed exempt from institutional review board regulations involving human and animal rights.
Statement of Informed Consent: Due to the retrospective nature of the study and publicly available data, this study was deemed exempt from institutional review board regulations including informed consent
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding: The author(s) received no financial support for the research, authorship, and/or publication of this article.
ORCID iDs: Charles Johnson 
https://orcid.org/0000-0002-1975-2005
William Newton
https://orcid.org/0000-0003-0338-9923
John Allen
https://orcid.org/0009-0002-1971-6191
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