Sandblasting Injury of Hand

What is the mechanism of injury? • Xray of the Week

Figure 1. Frontal and lateral plain radiographs of the left hand and lateral plain radiograph of the left forearm.

Figure 2. Frontal and lateral plain radiographs of the left hand and lateral plain radiograph of the left forearm demonstrating occupational sandblasting injury. A. Frontal x-ray of left hand showing radiopaque sand (red arrows) in the 1st metacarpal web space and extensive subcutaneous emphysema throughout the hand (yellow arrows). B. Lateral x-ray of left hand demonstrating radiopaque sand (red arrows) in the 1st metacarpal web space and around the adjacent proximal 1st phalanx. C. Lateral x-ray of left forearm showing subcutaneous emphysema (yellow arrows) extending along the anterior surface of forearm.

Discussion:

Sandblasting is a form of abrasive blasting that involves the propulsion of sand particles at high speeds to clean, smooth, or shape various industrial surfaces. Sandblasting injuries are classified as high-pressure injection injuries and can result in significant trauma that may require emergent surgery (1,2). Although there is widespread usage of these high-pressure tools, high-pressure injection hand injuries are rarely seen and account only for a small number of total hand trauma cases (1-3). In cases of limited exposure and small injection sites, the overlying soft tissue may look grossly intact, but the underlying tissue is where extensive damage can occur including tissue ischemia, chemical irritation, muscle destruction, compression effects, and widespread edema (3). Rarely, subcutaneous emphysema can occur due to communication with surrounding atmospheric air, injection of air from the high-pressure device, and creation of a one-way valve system (4).

The specific imaging features of sandblasting injuries and foreign bodies in general ultimately is determined by the composition of the material. Plain radiography is usually the first step in imaging hand trauma with suspected foreign body as it allows for potential classification of the material and location relative to other structures. Materials such as metal, glass, and stone, including sand, are readily picked up on plain radiographs and will appear radiopaque (Figs. 1,2) (5). Of note, wood and acrylic-based materials exhibit the opposite and will appear radiolucent on x-ray making the visualization of these materials difficult (5). Subcutaneous emphysema can be further visualized on conventional radiographs due to its lower density compared to surrounding soft tissues and bone (Figs. 1,2). CT can provide higher resolution and a precise measurement of the foreign body’s size and shape, although cross sectional imaging is rarely sought after in most cases (5,6). When concerning radiolucent materials, CT has greater utility in their detection when compared to conventional radiographs (5). Both CT and MRI can be utilized when surgery is in question and for assessing soft tissue, muscular, ligamentous, and tendinous damage (5,6). Sonographic features of most foreign bodies including stone will appear hyperechoic, but any air introduced to the surveyed area will lead to difficulty visualizing the foreign body (5).

Treatment of these high-pressure injection injuries involves prompt evaluation of the wound and emergent surgical debridement to ensure the patient maintains function of the affected area and to reduce the need for amputation (5,6).

References:

1. Amir A, Sagi A, Barr J, Rosenberg L. 'Sand-blaster' injuries. Injury. 1996;27(3):223-224. doi:10.1016/0020-1383(95)00206-5

2. Belsole RJ, Nolan M, Eichberg RD. Sandblasting injury of the hand. J Hand Surg Am. 1982;7(5):523-525. doi:10.1016/s0363-5023(82)80054-3

3. Verhoeven N, Hierner R. High-pressure injection injury of the hand: an often underestimated trauma: case report with study of the literature. Strategies Trauma Limb Reconstr. 2008;3(1):27-33. doi:10.1007/s11751-008-0029-9. PubMed Full Text: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2291478/

4. Fox A, Sheick H, Ekwobi C, Ho-Asjoe M. Benign surgical emphysema of the hand and upper limb: gas is not always gangrene--a report of two cases. Emerg Med J. 2007;24(11):798-799. doi:10.1136/emj.2007.046755 PubMed Full Text: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2658337/

5. Aras MH, Miloglu O, Barutcugil C, Kantarci M, Ozcan E, Harorli A. Comparison of the sensitivity for detecting foreign bodies among conventional plain radiography, computed tomography and ultrasonography. Dentomaxillofac Radiol. 2010;39(2):72-78. doi:10.1259/dmfr/68589458

6. Collins M, McGauvran A, Elhassan B. High-pressure injection injury of the hand: peculiar MRI features and treatment implications. Skeletal Radiol. 2019;48(2):295-299. doi:10.1007/s00256-018-3005-6

Corey Stump is a medical student and aspiring radiologist at the Marian University College of Osteopathic Medicine in Indianapolis, Indiana. Prior to medical school, he graduated summa cum laude from Wittenberg University where he received a B.S. degree in Biology. He is excited to pursue a career in Diagnostic Radiology with interests in medical education. He has produced a webinar titled “Navigating The Virtual Match; Program Directors vs. Medical Students” through the Academy of Online Radiology Education with other medical students and radiologists around the country in an effort to provide insight on the 2020 residency match. He is passionate about teaching and he hopes to provide a meaningful experience to medical students one day.

Follow Corey Stump on Twitter @corey_stump

All posts by Corey Stump

Kevin M. Rice, MD is the president of Global Radiology CME

Dr. Rice is a radiologist with Renaissance Imaging Medical Associates and is currently the Vice Chief of Staff at Valley Presbyterian Hospital in Los Angeles, California. Dr. Rice has made several media appearances as part of his ongoing commitment to public education. Dr. Rice's passion for state of the art radiology and teaching includes acting as a guest lecturer at UCLA. In 2015, Dr. Rice and Natalie Rice founded Global Radiology CME to provide innovative radiology education at exciting international destinations, with the world's foremost authorities in their field. In 2016, Dr. Rice was nominated and became a semifinalist for a "Minnie" Award for the Most Effective Radiology Educator.

Follow Dr. Rice on Twitter @KevinRiceMD

All posts by Kevin M. Rice, MD