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Short report
Non-infectious subcutaneous emphysema of the
hand: a case report and review of the literature
Tina Constantine,1 Umayya Musharrafieh,1 Abdallah Rammal,1 Sami Moukaiber,1
Rashid Haider2
1
Department of Family
Medicine, American University
of Beirut Medical Center, Beirut,
Lebanon
2
Department of Surgery,
Orthopedic Division, American
University of Beirut Medical
Center, Beirut, Lebanon
Correspondence to
Tina Constantine, Department of
Family Medicine, American
University of Beirut Medical
Center, Beirut, Lebanon;
[email protected]
Accepted 10 August 2009
ABSTRACT
Subcutaneous emphysema in the hand can result from
infectious and non-infectious aetiologies. Adequate
history, physical examination, laboratory studies and
imaging are needed to delineate the cause, to prevent
debilitating consequences and to avoid unnecessary
procedures and interventions. In this case report, an
18-year-old man sustained a trauma to the dorsum of
the hand after a fist fight, without any penetrating
objects, that resulted in instantaneous non-infectious
subcutaneous emphysema which resolved with
conservative management. A literature review of cases
of non-infectious subcutaneous emphysema is presented
here with an overview of the mechanism of injury, as
well as the course and management. Certain criteria are
also outlined to help differentiate between infectious and
non-infectious emphysema, which include laboratory
studies, imaging, timing and clinical symptoms.
CASE PRESENTATION
An 18-year-old man presented to the Family
Medicine Emergency Department 1 h after
sustaining trauma to the hand. The injury was due
to a fist fight, without any penetrating objects or
bite marks, resulting in two lacerations 0.5 cm each
over the first and fourth dorsum space and not
extending to the whole thickness of the dermis. On
physical examination, there was extensive subcutaneous emphysema (SE) and crepitus over the
dorsum of the hand extending to all fingers (figure
1). His vital signs were stable and there were no
signs of infection. The SE was progressive,
increasing in size, and there was erythema and
tenderness upon palpation and passive movement
of the fingers. There was no injury to vital structures of the hand, with normal range of motion of
all fingers. An x-ray of the hand and wrist showed
SE of the dorsum but no fractures or foreign bodies
(figure 2). An orthopaedic surgeon was consulted,
a splint was placed to minimise movement and the
patient received tetanus immunisation after
cleaning the wound. He was discharged on clindamycin and penicillin for prophylaxis. On follow-up,
the dorsum of the hand was still swollen with
crepitus but the SE did not extend beyond the wrist
area. Further follow-up revealed progressive
improvement in symptoms with full recovery.
DISCUSSION
Subcutaneous emphysema in the hand can result
from infectious and non-infectious aetiologies.
Adequate history, physical examination, laboratory
studies and imaging are needed to delineate the
cause, to prevent debilitating consequences and to
avoid unnecessary procedures and interventions.
Gas gangrene, a serious association with trauma
and emphysema, was found to occur after injury in
49% of patients, in 35% after surgery and in 16% of
patients it can occur spontaneously.1 The infectious
causes of SE in the hand are commonly caused by
gas-forming organisms such as clostridial infection,
anaerobic Streptococcus and some coliform bacteria.
Clostridial myonecrosis and infectious SE require
Figure 1 Photograph of the hand showing extensive subcutaneous emphysema and crepitus over the dorsum of the
hand extending to all fingers.
Emerg Med J 2010;27:383e386. doi:10.1136/emj.2009.080242
383
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Short report
Table 1
Reported cases of non-infectious subcutaneous emphysema (SE) of the upper extremity
Age
(years)
Type of injury
Mechanism
Course and complications
Sex
Laceration with knife to left forearm
One-way valve wound
F
30
6
Axillary air from invading squamous cell
carcinoma of bronchus with ribs
metastasis
Clean wound over the olecranon after a fall
from a horse
Hand and forearm high pressure injection
of air during scuba diving
Blackthorn penetration on the ulnar side of
the right wrist
Fistula between bronchus and chest wall
SE extended from the biceps to the distal
forearm, discharge on day 3, oral
antibiotics
Sudden death because of left-sided
pulmonary thrombosis
M
82
7
SE resolved after 1 week without surgical
intervention
F
59
8
Bilateral forearm SE due to high pressure
respiratory ventilator
Spread of free air through fascia and
interstitial tissue due to high intrathoracic
pressure
Factitious/self-inflicted
Recurrent soft tissue swelling of right
upper extremity
SE of dorsum of the hand following
excision of wrist ganglion and insertion of
suction drain
Small puncture wound of hand with
swelling of hand and forearm after
cleaning with compressed air
SE of left hand
Laceration of elbow with SE of UE
Bilateral cervicofacial, axillary and
anterior mediastinal SE after third molar
extraction and the use of an air turbine
dental head piece
Minor wound to web space skin with high
pressure pneumatic tool, extensive SE
with use of high vibration tool without
breach of skin
Large painless ulcero-vegetating lesions of
forearm (pseudocarcinomatous epidermal
hyperplasia) with SE
Thrombophlebitis of upper limb with SE of
right shoulder
Extensive soft tissue gas and swelling of
forearm
SE of finger following an injection injury
Pain and swelling of left upper extremity
SE of upper limb after air gun injury
Four workers injected concentrated hexafluoroethane into a finger, presented with
oedema, limitation of motion and SE
Massive SE and pneumomediastinum
after finger subtotal amputation with
barotrauma with air valve blast
SE of arm and forearm due to accidental
leak of halon gas from fire extinguisher
Ball valve mechanism
Suction drain did not work properly
Exposure of wound to compressed air
CT revealed pneumomediastinum
Ball valve mechanism
Use of high speed and high pressure
turbine introduced air through the
communicating fascial spaces of
parapharyngeal, neck and chest
Ball valve mechanism, high vibration
Injecting a foreign substance causing
epidermoid syringe metaplasia in the deep
dermis of the eccrine ducts
Recurrence of laryngeal cancer, formation
of a fistula due to radiosclerosis of soft
tissues of neck
Gas generated by the chemical reaction
between a metallic foreign body and
tissue fluid or spread of benzene
evaporation
High velocity injection injury
Self-injection of air
Air injection injury
Chemical injury
Barotrauma
High pressure injury
aggressive interventions such as wound debridement or amputation, high doses of antibiotics and hyperbaric oxygen therapy.2
Non-infectious SE is uncommon, and there are few case
reports in the literature. Although non-infective causes are not
necessarily benign, the majority tend to resolve rapidly with
minimal intervention.2 Various causes of non-infectious SE are
reported in the literature. The case presented here is probably the
first case of SE of the hand following a fist fight without bite
384
9
High air pressure injection injury
Ball valve mechanism
Ref
SE spreading to upper extremity reaching
mastoid, developed some compartmental
symptoms. Wound exploration,
fasciotomy and postoperative
physiotherapy
SE disappeared once patient was put off
ventilator
M
18
2
F
72
10
Referred to psychiatry
F
13
11
Compression of patient’s body.
Conservative management, resolved in
several days
Resolved after 48 h
SE spread to arm, shoulder, head, left
hemithorax, back, supraclavicular,
cervical, submandibular and periorbital
regions. Disappeared in 6 weeks
e
Complete resolution in 10 days with
conservative management
12
M
27
13
F
17
14
e
F
e
14
15
17
Benign course without signs of
inflammation or local pain
All lesions healed within few days using
an occlusive dressing
16
F
22
18
e
19
No treatment, resolved in few days
20
21
F
44
22
23
Treatment consisted of splinting, tetanus
immunisation and antibiotics, with rapid
recovery
Microsurgical repair of the injured finger
was performed. Resolution of SE and
pneumomediastinum was complete at
follow-up
Benign course
M
33, 39
24
M
28
25
e
e
26
marks or foreign objects. There is one case report of a 19-year-old
man who presented with SE of the dorsum of the hand after
punching someone, but radiological studies revealed the presence
of a tooth.3 The results of a literature review using Medline,
EMBASE and PubMed using the search terms ‘upper limb’ and
‘subcutaneous emphysema’ are summarised in table 1. The
causes of non-infectious SE reported in the literature include
emphysema due to pneumomediastinum, use of a high vibration
Emerg Med J 2010;27:383e386. doi:10.1136/emj.2009.080242
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Short report
Figure 2 X-ray of the hand and wrist showing subcutaneous
emphysema of the dorsum without any fractures or foreign bodies.
Table 2
tool with no apparent breach of the skin, high pressure pneumatic tool injection injuries, factitious cases which are selfinflicted, wound irrigation with hydrogen peroxide, skin laceration, blast injuries and generation of gas following wound
contamination with chemicals.2 Most of the reported cases of SE
of the upper limb resolved within a short period of time with
conservative management without resorting to aggressive
surgical interventions, except for the cases that had involved
blast injuries or foreign bodies. Many reported cases occurred due
to occupational hazards, either from tools used or chemical
injuries. Close observation is needed, even in non-infectious
cases, because of possible complications such as pneumomediastinum, compartment syndromes and spreading of subcutaneous emphysema in fascial planes (table 1). There are major
differences in the presentation of infectious and non-infectious
subcutaneous emphysema which are shown in table 2.
There are different postulated mechanisms of non-infectious
subcutaneous emphysema in the literature. Some of the mechanisms discussed include a ball valve mechanism with one-way
valve wounds, chemical reactions producing air, high pressure
injection injuries, blast injuries, following dental extractions or
fistulae with the respiratory system (table 2). In our case, the
wound acted as a ball valve mechanism where movement and
continued use of the limb causes air to be forced into the wound
with wide spread throughout the interfascial planes. The two
small lacerations in the dorsum of the hand provided air entry,
with continuous stretching and compression to the negative air
pressure space between the digital web spaces.4 5 When there are
no reported trauma, no localised or systemic findings and laboratory results are within the normal range, the possibility of
subcutaneous self-injection of air should be considered, especially
with the availability of needles and syringes.5
Management of non-infectious SE depends on the clinical
state of the patient. Stable patients can be discharged home on
oral antibiotics, with complete instructions regarding wound
care and signs or symptoms of infection. Serial follow-up visits
are needed to assess resolution of symptoms and wound healing.
If the patient needs to be admitted, close monitoring of vital
signs, performing serial examinations, irrigating the wound with
saline, changing the dressing every 6 h, administering tetanus
vaccination or immunoglobulin and broad-spectrum intravenous
antibiotics for 24 h are mandatory.6 It should be kept in mind
Criteria to distinguish between necrotising fasciitis (NF) and benign non-infectious subcutaneous emphysema (SE)
Criteria
Necrotising fasciitis
Benign subcutaneous emphysema
Ref.
White blood count
Serum sodium
BUN
MRI
>143109/l
<135 mmol/l
>15 mg/dl
Fascial inflammation, characterised by low intensity on
T1-weighted images and high intensity on T2-weighted images.
Absence of gadolinium contrast enhancement on T1-weighted images.
Can detect fascial necrosis. Useful in determining the extent of fasciitis
Air within the muscle
Presence of asymmetric fascial thickening and gas
are useful in evaluating suspected NF, can reveal
coexistent deep collections
Hypotension, fever, tachycardia, tachypnoea,
skin necrosis, purplish discolouration, bullae,
crepitance, tense oedema, erythema, warmth,
tenderness, swelling. Sensory and motor deficit
21 h after clinical symptoms, pathologist can establish
diagnosis of necrotising infection. Gram stain confirms
the usually mixed polymicrobial infection. Tissue biopsies
are best method to use when diagnosing NF
At least 12e18 h to produce clinically significant crepitus
Within normal range
Within normal range
Within normal range
e
27
Air disseminated in the tissue planes
e
6
No signs of sepsis or toxaemia. No signs of vascular,
sensory or motor deficit. Muscles are intact.
Crepitance, mild tenderness, swelling and erythema
2 4 6 7
Gram stain reveals no organisms. Cultures reveal
no growth. No necrotising infection on biopsy
30
Clinically significant crepitus develops within 6 h
4 5
x-ray
CT scan
Clinical signs
Tissue biopsy (culture,
Gram stain frozen section)
Timing
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27
27
28
29
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Short report
that non-infectious cases can have detrimental consequences. SE
of the wrist, for example, can extend to involve the whole upper
arm reaching the mastoid, with compartmental symptoms.2
Finally, surgical intervention is only justified if the extremity
deteriorates or the patient becomes haemodynamically unstable.
Postoperatively, physiotherapy should be recommended.2 Our
patient had a benign course and recovered uneventfully.
In conclusion, the importance of this case report is its rarity
and its similarity to more aggressive and life-threatening aetiologies. It is prudent that physicians can differentiate between
gas gangrene and non-infectious cases when faced with subcutaneous crepitus, by taking into consideration the timing from
the injury, clinical state of the patient and radiological and
laboratory findings. As such, aggressive, unnecessary and costly
interventions are avoided.
10.
11.
12.
13.
14.
15.
16.
17.
18.
Competing interests None declared.
Ethics approval This study was conducted with the approval of the American
University of Beirut Institutional Review Board.
Patient consent Obtained.
19.
20.
21.
Provenance and peer review Not commissioned; not externally peer reviewed.
22.
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Emerg Med J 2010;27:383e386. doi:10.1136/emj.2009.080242
Downloaded from http://emj.bmj.com/ on September 16, 2016 - Published by group.bmj.com
Non-infectious subcutaneous emphysema of
the hand: a case report and review of the
literature
Tina Constantine, Umayya Musharrafieh, Abdallah Rammal, Sami
Moukaiber and Rashid Haider
Emerg Med J 2010 27: 383-386
doi: 10.1136/emj.2009.080242
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