Necrosis of the 4th and 5th Digits after Intra-Articular Injection of Diazepam into the Wrist

Abstract

A 75-year-old woman presented with progressing pain, cyanosis, and hypaesthesia in her left hand after an intra-articular injection with diazepam into the wrist for osteoarthritis-related pain. Due to an iatrogenic intra-arterial injection, malperfusion of the ulnar digits developed. Angiography revealed blockage of perfusion of the 4th and 5th digits. Despite intra-arterial lysis, heparinisation, and vasodilatation, perfusion could not be reinstalled. Necrosis of the distal phalanges of the 4th and 5th digits developed, which had to be treated with amputation. The pathomechanism of tissue damage and the treatment options after intra-arterial injections are reviewed and discussed.

The incidence, significance, and management of accidental intra-arterial injection: a narrative review

“…12,44 Similarly, midazolam (another highly lipophilic drug, though not supplied in a lipid formulation) has been injected intra-arterially without significant complications compared with its class partner (and less lipophilic drug) diazepam, where arterial injection has been associated with significant morbidity, including the need for amputation. 9,11,20,25 The potential for damage depends on the drug injected, and also its formulation. For example, in the case of inadvertent intra-arterial injections of paracetamol, one preparation utilizing a benzyl alcohol formulation was reported to cause gangrene, while injection of an aqueous paracetamol formulation was benign.…”

“…Five cases involved diazepam, four involved penicillin or its analogues, and one each involved clindamycin or paracetamol in benzyl alcohol. 9,15,17,21,[24][25][26]32,34 The typical clinical courses from these reports are shown in Table 2. Of the 11 patients in these publications, eight required amputation, two suffered from chronic pain, and one developed distal necrosis of the fingers.…”

Accidental Intra-Arterial Injection during Test Dose of Injection of Benzyl Penicillin: Complications and Management—A Case Report

“…Although most cases of unintentional arterial cannulation involve the radial artery branches of the forearm and hand, superficial ulnar arteries also have been reported to be involved in 2% to 3% of patients [10] and 12 variations of the superficial palmar arch and 7 variations of the deep palmar arch have been described [1]. In our case while giving the test dose of Benzyl penicillin, accidental injury to the wall of ulnar artery or its branch or an abnormal/aberrant superficial branch of ulnar artery might have taken place as all fingers except thumb were affected [1] [2].…”

“…Various treatment options have been proposed that include 1) immediate elevation of extremity to heart level; 2) immediate and adequate Heparinisation; 3) sympathetic block; 4) narcotic analgesic to control pain; 5) reversal of spasm; 6) maintaining and /or re-establishing blood flow to the distal portion of extremity; 7) thrombectomy to establish pulses in major vessels where needed; 8) treating any sequeale of vascular ischemia (oedema, compartment syndrome, gangrene and rehabilitation [1] [2] [10]; 9) surgical treatment of gangrenous areas with amputation of large areas of tissue necrosis [1] [6].…”