Ther. ]{ev., 40:J LEONARD~Jointcd. J.,~ction withAcademy

osis Treated by the FUsion"

Surg., 39-A::; and SNE~SON, ROy:

:valuation of Patients forAcademy of. Orthopaedi~

ical-Spiae Fusion for Neck

!h to ~’ongra~ulate Dr. Garretttire work on Patients withdlere this work has beenwhich Dr. Nickel and hisin overcoming these¯ s~ra~ed ~t~.e safety of ma~ficJts. When these patientsre and after operation,benefits of stabilization of the~d ~urgical help. The benefitJOtlS.

; Hospital two years agoService a~ Gillette State¯ evised and used ~t Ranchostraction upon the head ~,eration of the Department~hnonary f~ction in thesets in determ~iag the need forvery real.all orthopaedic surgeons wholdren, adolescents.lect.tying the stiffness so oftenarefully ~terpreted. It m~generalized paralysis make ain some of these would be

~d by undesirable~ble features in this method of: severe seoliosis in the"zed adult."strophy and certain forms ofbeen enthusiasticallyd, futile attempts at external :~ surgeons. I feel that~entsare often goodme the opportunity to s~mities will be made morenateri~lly incre~ed thereby.annot be at all critical of t~aey should be.

;tease-Gun Injuries of the Hand*~:IER]3ERT I-I. STARK, M.D., JAMES i’¢. WILSON, M.D., AND

JOSEPH H. BOYES, M.D., LOS ANGELES, CALIFORNIA

irating wounds caused by grease or oil injected into the fingers andncommon. Since the first description in 1937 ~, eighteen case reports

in the English literature; four injuries were caused by injection of,a.** and fourteen injuries were caused by injection of lubricating

Photographs of a few other injuries, together with brief

of them, have been included in textbooks of hand surgery ~.~.~.~.(is undoubtedly correct in his belief that such injuries occur more often{ are reported. We have treated five patients with grease-gun injuries ofdm’ing the past six years. The purpose of this paper is to report ourwith ~hese injuries, to emphasize their seriousness, and to stress thatsurgery is the best method of treatment.

lubrication of machines and the carburetion of dieseI engines are accom-forcing a fine stream of grease or oil under high pressure through a tinythe jet stream strikes the hand or finger, it pierces the skin and fills

spaces wkh oil or grease. The extent of damage may not be apparent atand the patient often continues to work. Within a few hours, however,rues intense, and the injured part becomes numb and pale. In closed

!such as the pulp of the finger tip, ischemia develops rapidly.

Mason and Queen gave a detailed description of the tissue changessuch injuries. Damage to the hand is caused by isehemia, chemical

and infection. Sudden distension produces isehemia.which~ j.f u.nre!ie..xed~necrosis. Immediate removal of the retained grease decompresses the

lessens the tissue irritation, and rids the wound of contaminated

grease-gun injuries should be treated as surgical emergencies. From agrease will disseminate th’rough the tissues; it will not necessarily

soft-tissue planes. The palm and wrist may be distended withhas entered a finger. If the entry is in the mid-volar line of a finger,

sheath may be filled with grease or oil throughout its length.pressure is relieved the tendon will die, even though infection does

incisions over the point of entry are inadequate. All involved par~sthoroughly explored in a bloodless field. A finger should be openedmid-lateral incision throughout its length and, if involuted, the palmopened through an appropriate separate incision. All possible foreign

should be mechanieally removed: a blunt curette is the most useful tool.

non-essential tissue shauld be sharply excised. Damaged tendonshould be removed, and only small proximal and middle segment pulleys

¯ be preserved. Even with meticulous care and the utmost patience, some

material will still remain. We have not used oil solvents, such as ether,we believe that such solvent,’~ are harmful to living tissues. The incisions

closed, and the hand should be immobiliaed in a position of rune-antitoxin or toxoid should be given.

’ Read at the~nual Meeting of the Western Orthopedic Association, Coronado, California,1960.

NO. 4, JUN~ 1961 485

H.H. STARK, .l.N. W]LSOX, AND J. H. BOYES

C~s~ l. (Figs. I-A t.hrough t-F): An Mrcraft mechanic, thirt.y-tJ~ree years oh two days afte~ grease, under pressure cf :L000 po,mds per sqmtre inch. had entered th,of the right long fit~ger at the I)roximal flexion crease. The entire long linger and the of the pMm were swollen. The dorsal skin over the proxinml segment of the finger wasand the index, long, ~nd ring fingers were nmnb.

Case 1. The dorsal skin was blistered and swollen forty-eight hours after grease had enteredvelar surface of the long finger.

Fro. 1-B Fro. I-CFig. I-]3: The dorsum of the finger was filled with grease, the mechanical rein(

facilitated by use of a curette. Note ~he ischemic necrosis on the dorsum.Fig. I-C: The velar soft tissues were infiltrated with grease, bnt the tendon sheath was

A probe is beneath the digital nerve. "

The long finger was opened through a mid-laterM incision. The dorsal and velar soft tissues’t, he finger were distended with ~chiek grease, but the tendon sheath was intact. The pahnopened through a separate incision, was also filled with grease. As much grease as i)ossible ~asmoved from bofh the finger and the pMm with a eurett(~ and by sharp excision. The wonndsloosely closed and heMing was nneomplieated.

Eleven months after iniury extension of the finger was normal and voluntm3, flexionthe finger tip to u~ithin one-quarter inch of the mid-l)almar crease.

Only four of ~he eight.een eases reported in the li~erafure were ~reatedearly and adequate surgery. In these four there was a reasonably months afi~

inch of t!result, although no patien¢ had a full range of mot, ion in the injured fingerBv cont.rast, when similar injuries were treated by conservative measures,~ 2: A machi~:ration was usually required, of 15,000

TIlE JOURNAL OF BONE AND JOINT ~URGEtlY

.l.H. BOI’ES

thirty-three years old,Ire inch, had entered the.tire long finger and the dist.l segment of the finger was

hours after grease had ent

GREASE-GUN INJURIES OF THE ttAND487

FzG. 1-D, u of d~c palm ~vas exposed throug]~ a separate ip.cisiou. The :oft-tissue

"vitt~ ~rease and uijacent neurovascuiar bttlld[cs were cOllll)rcsst~d, hlllnediaLc

mandatory to prevent irreversible ischemia-

FIG.

as possible was removed with_ a cur~z~e, and al~ impregnated non-essentiM t~ssue~ removM of the grease was impossible.

FIO. t-C

, mechanical rem(e dorsum.but the tendon sheath was

[’he dorsal andh was intact. Theks much grease as possiblesharp excision. The wounds i

aal and vohmtary flexion

literature were

s a reasonablyin the injured fin

:lservative measures,

FIG. I-F

months gfter injury, all fingers extended normally. The long finger flexed %0 within~id-palmar crease.

A machi~ist, who worked on oil well pipelines, was seen after tmrefined oil delivered at15,000 potmds per square inch bhrough a one_t.hir~y-seeond-ineh opening sgruck his

n the radial side of ~he mtddle flexion crease. The hand swelled. Iloentgenograms

AL OF nONE AND JOINTNO. 4, JUNE 1961

Fm. 2-A Fro. 2-BFig. 2-A: Case :3. Tim tendoB shead~ in the finger and pahn was distended wilh

sheath iB the palm ru[)tured, and grease extravttsated into the soft tissues.Fig. 2-B: The al)l)earance o{ the tmldon after partial removal of the sheath, C, rea~,

wid~in the sheath {’xuded from the opeBing.

Fro. 2-CThe appearance of the finger ":hirteen months after injury. Motion remains

showed air in the dorsum of the finger and hand: a diagBosis of gas gangrene waswas treated with gas antitoxin ~md antibiotics.

Teu days later, on our first, examination, the imlex finger was alreadydorsum of the hand was swollert, part.ieularly over the metacarpal of the index finwas amput.~ed through the base of the metacarpal. Grease had exteBded along tcular bundle into the palm The flexor-tendon sheat, h was intact,, although sui’round~foreign material. Considerable grease was found on the dorsuln of the proximalfinger aud between the metaearpal~ of the index and long fingers, tIealing

Decompression by removal of the foreign material will usuallygrene. Since complete removal is not possible, some fibrosis andoccur. If the flexor-tendon sheaths are directly involved, as in theconsiderable loss of function is more likely.

C.~sE 3 (Figs. 2-A through 2-C): A gas station attendant, twenl;y-nilm vett, l’8 old.forty+ight hours after a je~ stream of grease from a lubricating gun had perpetrated theaspect ~f the base of his left tong finger. The pa~ieBt stated that half a cup ofbeen expressed from the wound openiBg. At operation, the flexor-tendon sheath was founddistended from the finger tip to the proxinml part of the p:dm. Large amounts of grea~ ~

TIlE JOUJ/NAL 0I," BONE AND JOI2CF

GREASE-GUN INIURIES OF THE HAND 489

Fro. 2-B:lger and pahn was distended withtte(l into the soft tissues.,atrial removal of’ the sheath. Grease

~ injury. Motion remains extremeh,

~gnosis of gas gangrene was made.

.dex finger was already gnuhe metacarpal ofreuse had extended alang~th was intact, althoughthe dorsum of the proximallong fingers. Healing was

~n material will usuallye, some fibrosis and scarnn~y involved, as in the

zttendant, twenty-nine yearslubricating gun had penetrated the~ted that half a cup~, the flexor-~endon sheath wasthe pahn. Large amounts of grea~

Case 4. The left hand twelvehad penetrated the

The wound of entry was in-:my ). The tendon sheath

w:~s ,listended with grease.The london sheath in the

¢~i:.~.nded: all grease wt~sbin ~he tendon sheath.

grease has been re-)ortion of tendon

excised. Pulleys were

FIG. 3-C

of purulent-appearing material were removed ~hrough two incisions---one in thein the palm. The tendon sheath xvas excised, but narrow pulleys in the proximal__

} segments of the finger were preserved. The palmar incision was loosely closed over aincision was closed loosely without drainage. The purulent-appearing material

emulsified fat ’=, since no organisms were reported from cultures of this material.occurred, but motion of the long finger was greatly restricted. Six months later an

made to improve flexion by ~;enolysis. There was extreme scarring throughout thepalm, which severely compromised the results of the secondprocedure. Thirteen

injury, the long finger could only be flexed voluntarily to within two inches of thewas negligible motion of the two interphalangeal ioints, but, since these

flexion, the patient was able to use the finger for many activities and did not

a patient is seen several days after injury and salvage of the i)arts

immediate removal of the retained grease will minimize the inevita-and prevent the formation of chronic, draining olemata n

(Figs. 3-A through 3-C) : An airplane factory worker, fifty-two years old, was seen tenet of lubrication oil from a high-pressure grease gun had penetrated the volar surface

of his left long linger. First-aid treatment had consisted in expressingsmall wound of entry. On examination ten days after injury there we.re numbness

the finger, swelling in the distal part of the pahn, and marked stiffness of all fingers.the tendon sheath of the long finger was found to be filled with grease; complete

of the grease was impossible and the tendon sheath was excised. The wounds healed with-

’tie JOUIINAL OF nONE AND JOINT NO. 4, JUNE 1961

490 H. If. STARK, J. N. WILSON, AND J. It. BOYEs

Fro. 4-AFro. 4-BFig. 4-A: Case 5. Photograph shows a necrotic wound with exposed profundus ten.

after grease penetrated the long finger near the distal flexion crease.Fig. 4-B: The finger was salvaged by resurfacing with an abdominal pedicle flap.

out. complication, but five months af~:er injury the,’e was still marked stiffhess of all

In neglected eases, amputation is often the best treatment, butreconstruction is indicated and the result rewarding ~

Cas~ 5 (Figs. 4-A and 4-B): An oil well worker, thirty-three years old, was seenafter a jet stream of carbonox--a mix~an,e of soda lime, dry clay, oil, and water--delivered ipounds of pressure, had penetrated the volar surface of the right long finger near the distal’crease. Initial treatment was reported as being wound d6bridement. Examinationextensive defee~ of the skin with exposed flexor tendons--the result of unrelieved isch~

After resurfaeing the volar surface of the distal part of the finger with an abdominal.flap, the distal joint was fused, the profundus tendon was excised, and the sublimisfreed from sear tissue. Useful fuuetion was restored and the finger tip flexed voluntarily to~one inch of the mid-palmar crease. The finger tip, however, was numb due todamage. ~’

SUhI~AI~y

Grease-gun injuries are an undesirable side effect of our too(Since methods of high-pressure lubrication are used in automobile,missile industries, more such injuries can be expected. The seriousness of:injuries should be recognized so that prompt and adequate treatmentthe resulting disability.

Grease-gun injuries of the hand are best treated by immediatemoval of as much of the grease as possible. This will prevent ischemicand reduce fibrosis and scarring. "

I~EFERENCES1. BELL, R. C.: Grease-Gun Injuries. British J. Plast Surg, 5- 138-1

. .2. BROOKE, R., and ROOKE, C. J ¯ Two ~ ..... v o " ¯ ~. 4~ 19521939. "" ~- .... -- ~rease-~n finger. ~ritish Med.

3. BUNNELL, STERLING: Surgery of the Hand. Ed 3 Philadel " , .4. B~, J. J.: Grease Gun Ini "~ r _. ¯ _phm J B. Lippincott Co.,-,un ..... Am. Mud. Assn., lzb: 405-407, 19445. Bv~E, J. J. : The Hand: Its Anatomy and Diseases. Springfield, Illinois, Charles

1959. ’6. D~ac, D. E.: Hand Injuries Due to Injection of Oil at High Pressure. J. Am.

I10: 1747, 1938.7. Fax~, A. E.: The Care of Minor Hand Inju6es St L ’ ,8. HAR~SON. RICHARD" ’Gr .... ~ ..... . ~ .: , ; Qms The C V. Mosbv. ¯ .~’~u~ l~Jury. ~rl~lS~ d. ~ur - _ ~ ~9. H~en~s, J. E.. Penetratmn of Tissu~ a,, n:~ ~,, ,. , ga 46. 514 251o, 1959.

~ 0~ ~e~ uu under ~ressure. O. Am. Med.2848-2849~1941.10. ,-, .-’ .: ¯ .

Masos, M L, and Q~E~, F. B.. Grease Gun Injumes to the Hand. Quart. Bull.Umv. Med. Seh.~ 15: 122-132, 1941.

TIIE JOURNAL OF BONE AND

AND J. H. BOYEs GRE_~SE-GUN INJURIES OF THE HAND491

it.: Grease-Gun Injury to the Hand¯ Value of Early Treatment. British Med. J.,

~’AKEFIELD, A. R. : Surgery of Repair as Applied to Hand Injuries. Ed. 2.Williams and Wilkins Co.. 1960.Penetration of Tissue b~ Fuel Oil under High Pressure from Diesel Engine.

~sn., 1{}~; 866-867, 193"/.i~,.ne~ration of Tissue by CJ~rease nnder Pressure of 7,000 Pounds. J. Am. ~ied.

i:-:)08, i939.:Grease-Gun Injuries. University Leeds ~ied. J., 2." ]25-129, 1953.md Cn~ISTL~N, S. G.: Grease Gun Injury. A Case Report. Indust. Med., 24:

\ FIG. 4-Bmd with exposed profundus ~en,al flexion crease.wi~h an abdominal pedicle flap.

~ was still marked stiffhess of all fin

~ the best treatment, bnt.~warding ~.~.

r. thirty-three years old, was seen~e, dry clay, oil, and water--dell.of the right long finger near the di)trod dSbridement. Examination’.ms--~he result of unrelieved ipart of the finger with an abdomi[*n was excised, and the sublimis.nd the finger tip flexed volunowever, was numb due to

de effect of our modernre used in automobile,

expected. The seriousnessand adequate treatmen~

t treated by immediatethis will prevent ischemic~

¯ Surg., 5: 138-145, 1952.ease-gun Finger. British Med.

?hiladelphia, J. B. Lippincottssn.. 125: 405-407, 1944.s. Springfield, Illinois,

)il at High Pressure. J. Am.

;. Louis, The C. V.J. Surg., 4~: 514-515, 1959.Under Pressure. J. Am. Med.

!d. J., 58: 17Y-178, 1959.es to the Hand. Quart. Bull