You are here

Article Text

Article menu

Download PDFPDF

A case of benign subcutaneous emphysema
Free
  1. Max Alexander Clayton-Smith1,
  2. Niroshan Sivathasan2
  1. 1Department of Adult Intensive Care Unit, St Mary's Hospital, London, UK
  2. 2Emergency Department, Joondalup Health Campus, Joondalup, West Australia, Australia
  1. Correspondence to Dr Max Alexander Clayton-Smith, maxclaytonsmith{at}gmail.com

https://doi.org/10.1136/bcr-2013-202261

Statistics from Altmetric.com

    Request Permissions

    If you wish to reuse any or all of this article please use the link below which will take you to the Copyright Clearance Center’s RightsLink service. You will be able to get a quick price and instant permission to reuse the content in many different ways.

    Description

    A 53-year-old man presented to the emergency department with a swollen left forearm 2 days after sustaining a left elbow injury falling off a ladder. There was mild pain at the elbow that had responded well to ibuprofen and there were no symptoms of sensory disturbance distal to the injury. On examination, there was a 4 cm2 abrasion on his elbow with a small, 0.5 cm long, penetrating wound 1 cm distal to the olecranon and crepitus on palpation of the skin from his distal bicep to wrist but no associated heat or erythema. He was systemically well, vital signs were normal with a white cell count <10 × 109/L and C reactive protein <10 mg/L. Radiographs (figures 1 and 2) showed no fracture but a radiolucent layer beneath the skin of the forearm consistent with subcutaneous emphysema. This was confined to the arm with no extension to the chest wall or signs of pneumothorax. Intramuscular gas was not present, making Clostridial myonecrosis (gas gangrene) unlikely.

    Figure 1
    Figure 1

    Lateral view of the left forearm demonstrating subcutaneous emphysema extending to the wrist.

    Figure 2
    Figure 2

    Anteroposterior view of the left elbow and upper arm showing gas confined within the subcutaneous tissue with no evidence of tracking to the chest.

    Subcutaneous emphysema, defined as gas or air within the subcutaneous tissues, has many causes including following trauma or surgery, pneumothorax, oesophageal rupture, high-pressure injection injury and infection with gas-producing organisms. It is also important to exclude a compartment syndrome (typically associated with an abdominal distribution or high-pressure injection injuries) being caused by the gas. In this case it was considered to have arisen as a result of a valve type mechanism allowing air to enter via the elbow wound.1 Discharged on prophylactic antibiotics (cephalexin) to cover potential wound contamination, the patient made a full recovery.

    Learning points

    • Distinguishing between benign subcutaneous emphysema and emphysema secondary to inoculation with Clostridium perfringens or from gas-forming organisms causing necrotising fasciitis is vital to direct management and prevent unnecessary surgical intervention.

    • A detailed history enquiring about surgery, trauma, time since injury and systemic symptoms along with measurement of physiological parameters, and blood inflammatory markers help to identify the cause of subcutaneous emphysema.

    • Benign subcutaneous emphysema usually resolves spontaneously though severe cases may require surgical decompression.

    Reference

    1. ↵
      1. Fox A,
      2. Sheick H,
      3. Ekwobi C,
      4. et al
      . Benign surgical emphysema of the hand and upper limb: gas is not always gangrene—a report of two cases. Emerg Med J 2007; 24:798–9.
      OpenUrlAbstract/FREE Full Text
    View Abstract

    Footnotes

    • Contributors MAC reviewed the patient, co-authored the manuscript and is the first author. NS co-authored the manuscript and is the senior author.

    • Competing interests None.

    • Patient consent Obtained.

    • Provenance and peer review Not commissioned; externally peer reviewed.