High-pressure injection injury of the hand. Underestimation of injury severity

A 44-year-old man sustained a high-pressure injection injury of the left index finger with hot hydraulic oil in an occupational accident. On presentation to the occupational physician 4 h later the wound was irrigated and cleaned. At this time X-ray diagnostics, wound revision, administration of antibiotics and immobilization were not performed. The following day the patient presented to a hospital with painful swelling and reddening of the left index finger where an emergency surgical wound revision, administration of antibiotics and immobilization of the finger were performed due to a phlegmon of the flexor tendon. Despite subsequent revision operations, necrosis of the flexor tendon sheath occurred with a skin subcutis defect necessitating a full thickness skin transplantation and ultimately operative fusion of the distal interphalangeal joint of the index finger. After a total period of treatment of 9 months the patient still presented with local soft tissue swelling and paresthesia as well as a limited range of motion of the proximal interphalangeal joint. The patient filed a complaint for wrong treatment of the high-pressure injection injury in terms of an inaccurate examination and lack of administration of antibiotics at the first presentation. The expert opinion of the arbitration board ascertained medical malpractice at the first presentation. An emergency surgical wound revision had already been indicated at the first presentation and the revision procedures would have been less extensive and it was highly probability that surgical fusion of the distal interphalangeal joint could have been avoided. The arbitration furthermore concluded that iatrogenic maltreatment led to a phlegmon of the flexor tendon with the need for subsequent revision operations including surgical fusion of the distal interphalangeal joint which resulted in an affected grip control. The delay in surgical treatment must be considered as the reason for the much worse initial situation that finally led to the functional impairment of the left index finger.