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A 73 year old woman presented to accident and emergency (A&E) with history of fall and sustaining a trivial laceration to the extensor aspect of the left olecranon. The wound was cleaned and closed with adhesive skin strips. Radiography showed no abnormality. She was discharged. She was referred back to A&E the following day by her general practitioner because of extensive swelling on the dorsum of the hand and forearm.
On examination she had surgical emphysema extending from the tips of the fingers to the mid-arm. There was no clinical evidence of infection in the arm. Radiography of her arm and forearm confirmed extensive surgical emphysema in the superficial tissues extending from mid-humerous to the hand (fig 1). The chest radiograph showed no abnormality. Wound swabs and blood cultures identified no pathogens. The swelling gradually resolved and had completely settled by final review, seven days after the injury.
Subcutaneous emphysema affecting an isolated limb is rare. It is important to differentiate between gas in the soft tissues secondary to infection and other causes of subcutaneous emphysema. Infection with gas forming organisms usually takes around 18 hours to produce clinically detectable crepitus. Subcutaneous emphysema from a non-infective cause is normally present much earlier. Signs of infection such as erythema, fever, systemic upset, and increased WBC count are not associated with non-infective causes. The presence of gas within the muscle bellies, as well as in the soft tissue, is suggestive of a deep seated infection with gas forming organisms.1
Treatment for serious infections resulting from gas forming organisms include high dose antibiotics, wound exploration and extensive wound debridement.2
Subcutaneous emphysema in an isolated limb has been described secondary to a number of causes, including after perforation of appendix, migration of fracture fixation device, irrigation of wound with hydrogen peroxide, air gun injury, dental extraction.3
In the case described, the history, the lack of clinical signs and the laboratory investigations all mitigate against infection being the cause. It has previously been reported that air can be trapped in tissues deep to relatively small wounds and it is hypothesised that this results from air being sucked into the wound, secondary to the movement of the limb.3
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