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Hiruma K, Suzuki K, Kato A, Yamaga H, Nakamura M, Inoue G, Kaki Y, Miyamoto K, Yagi M, Dohi K. Benign noninfectious subcutaneous emphysema with minor injury: A case report. Heliyon 2022; 9:e12317. [PMID: 36691541 PMCID: PMC9860412 DOI: 10.1016/j.heliyon.2022.e12317] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2022] [Revised: 11/30/2022] [Accepted: 12/06/2022] [Indexed: 12/24/2022] Open
Abstract
Posttraumatic subcutaneous emphysema, which can be benign and noninfectious, is associated with necrotizing fasciitis. Rarely, extensive emphysema occurs after a minor traumatic injury. A 23-year-old man came to our hospital with extensive emphysema, ranging from the left hand to the axilla, after a minor injury. Necrotizing fasciitis was suspected. Based on the blood and imaging tests, necrotizing fasciitis was not actively suspected. He was admitted and observed for one day, and he was discharged the following day. The mechanism by which air can enter through a small injury is unclear, but the one-way ball-valve mechanism is the most commonly proposed explanation. The nontraumatic causes of non-infectious subcutaneous emphysema include insect bites, skin biopsies, and the use of shock absorbers. Since it developed from a minor wound, other mechanisms, aside from the one-way ball-valve, were possibly involved. Based on the imaging results of this case, the air was predominantly distributed in the subcutaneous tissue along the neurovascular bundle. The relatively sparse tissue likely caused the extensive subcutaneous emphysema. While evaluating post-traumatic subcutaneous emphysema, benign and noninfectious cases should be differentiated to prevent unnecessary therapeutic intervention.
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Affiliation(s)
- Kaede Hiruma
- Department of Emergency and Disaster Medicine, Showa University, 1-5-8 Hatanodai, Shinagawa-ku, Tokyo 142-8666, Japan
| | - Keisuke Suzuki
- Department of Emergency and Disaster Medicine, Showa University, 1-5-8 Hatanodai, Shinagawa-ku, Tokyo 142-8666, Japan,Corresponding author.
| | - Akihito Kato
- Department of Emergency and Disaster Medicine, Showa University, 1-5-8 Hatanodai, Shinagawa-ku, Tokyo 142-8666, Japan,Department of Emergency and Disaster Medicine, Showa University, Yokohama Northern Hospital, 35−1 Chigasaki Chuo Tsuzuki-ku, Yokohama 224-8503, Japan
| | - Hiroki Yamaga
- Department of Emergency and Disaster Medicine, Showa University, 1-5-8 Hatanodai, Shinagawa-ku, Tokyo 142-8666, Japan
| | - Motoyasu Nakamura
- Department of Emergency and Disaster Medicine, Showa University, 1-5-8 Hatanodai, Shinagawa-ku, Tokyo 142-8666, Japan
| | - Gen Inoue
- Department of Emergency and Disaster Medicine, Showa University, 1-5-8 Hatanodai, Shinagawa-ku, Tokyo 142-8666, Japan
| | - Yuki Kaki
- Department of Emergency and Disaster Medicine, Showa University, 1-5-8 Hatanodai, Shinagawa-ku, Tokyo 142-8666, Japan
| | - Kazuyuki Miyamoto
- Department of Emergency and Disaster Medicine, Showa University, 1-5-8 Hatanodai, Shinagawa-ku, Tokyo 142-8666, Japan
| | - Masaharu Yagi
- Department of Emergency and Disaster Medicine, Showa University, 1-5-8 Hatanodai, Shinagawa-ku, Tokyo 142-8666, Japan
| | - Kenji Dohi
- Department of Emergency and Disaster Medicine, Showa University, 1-5-8 Hatanodai, Shinagawa-ku, Tokyo 142-8666, Japan
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Saela S, Decilveo A, Isaac R, Patel DV. Traumatic subcutaneous emphysema of the hand/forearm: A case report. Chin J Traumatol 2022; 25:395-399. [PMID: 35450804 PMCID: PMC9751530 DOI: 10.1016/j.cjtee.2022.04.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/09/2021] [Revised: 03/18/2022] [Accepted: 03/23/2022] [Indexed: 02/04/2023] Open
Abstract
Subcutaneous emphysema is commonly associated with infection caused by gas-producing organisms. In this case report, we describe a rare instance of traumatic subcutaneous emphysema of the hand and forearm caused by a puncture injury to the first web space of the hand. Our objective is to increase awareness of the potential for seemingly minor trauma to cause entrapment of significant air in subcutaneous tissues, thereby decreasing the likelihood that a clinically benign-appearing patient will be started down an unnecessarily aggressive treatment pathway. A 16-year-old, otherwise healthy white female, presented to the pediatric emergency room with an impressive amount of subcutaneous emphysema that developed over a 12-h period after sustaining an accidental laceration to the first web space of her right hand. She appeared nontoxic and had a clinically benign presentation. A comprehensive work-up was performed. She was splinted by the orthopedic surgery resident on call, and was admitted to the Pediatric Intensive Care Unit for overnight monitoring. She received tetanus vaccination and broad-spectrum antibiotics. The patient was discharged 2 days after admittance, with a splint applied to her right hand and forearm. She undertook home-based physical and occupational therapy. She had a pain-free range-of-motion in the right wrist, elbow and shoulder. The swelling in the right hand subsided completely. Although initially alarming, traumatic subcutaneous emphysema in an otherwise healthy patient from minor wounds (as featured in this case) does not necessarily mean one ought to proceed down an aggressive treatment algorithm. Careful evaluation of the patient's history, clinical examination findings, and determination of the Laboratory Risk Indicator for Necrotizing Fasciitis score can help guide physicians in the management of traumatic subcutaneous emphysema and potentially avoid unnecessary and costly interventions.
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Affiliation(s)
- Stephen Saela
- Department of Orthopaedic Surgery, St. Josephs University Medical Center, Paterson, NJ 07503, USA,Corresponding author.
| | - Alexander Decilveo
- Department of Orthopaedic Surgery, St. Josephs University Medical Center, Paterson, NJ 07503, USA
| | - Roman Isaac
- Department of Orthopaedic Surgery, St. Josephs University Medical Center, Paterson, NJ 07503, USA
| | - Deepak V. Patel
- Department of Orthopaedic Surgery, St. Josephs University Medical Center, Paterson, NJ 07503, USA,Department of Orthopaedic Surgery, Seton Hall University, South Orange, NJ 07079, USA
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Runer A, Schneider F, Mayr R, Dammerer D, Roth T, Liebensteiner M, Arora R, Raas C. Blistering of the entire lower limb after knee arthroscopy: Benign Subcutaneous Emphysema, Gas Gangrene or Necrotizing Fasciitis? A case report and review of the literature. Trauma Case Rep 2021; 35:100513. [PMID: 34386570 PMCID: PMC8342774 DOI: 10.1016/j.tcr.2021.100513] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/18/2021] [Indexed: 12/02/2022] Open
Affiliation(s)
- Armin Runer
- Dept. of Orthopedics and Traumatology, Medical University of Innsbruck, Innsbruck, Austria
| | - Friedmann Schneider
- Dept. of Orthopedics and Traumatology, Medical University of Innsbruck, Innsbruck, Austria
| | - Raul Mayr
- Dept. of Orthopedics and Traumatology, Medical University of Innsbruck, Innsbruck, Austria
| | - Dietmar Dammerer
- Dept. of Orthopedics and Traumatology, Medical University of Innsbruck, Innsbruck, Austria
| | - Tobias Roth
- Dept. of Orthopedics and Traumatology, Medical University of Innsbruck, Innsbruck, Austria
| | - Michael Liebensteiner
- Dept. of Orthopedics and Traumatology, Medical University of Innsbruck, Innsbruck, Austria
| | - Rohit Arora
- Dept. of Orthopedics and Traumatology, Medical University of Innsbruck, Innsbruck, Austria
| | - Christoph Raas
- Dept. of Orthopedics and Traumatology, Medical University of Innsbruck, Innsbruck, Austria
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Mack JA, Woo SL, Haase SC. Noninfectious subcutaneous emphysema of the upper extremity. J Hand Surg Am 2015; 40:1233-6. [PMID: 25910589 DOI: 10.1016/j.jhsa.2015.03.012] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2015] [Revised: 03/02/2015] [Accepted: 03/05/2015] [Indexed: 02/02/2023]
Affiliation(s)
- Jacob A Mack
- University of Michigan Medical School, Ann Arbor, MI
| | - Shoshana L Woo
- Section of Plastic Surgery, Department of Surgery, University of Michigan Health System, Ann Arbor, MI
| | - Steven C Haase
- Section of Plastic Surgery, Department of Surgery, University of Michigan Health System, Ann Arbor, MI.
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Cook IF. Best vaccination practice and medically attended injection site events following deltoid intramuscular injection. Hum Vaccin Immunother 2015; 11:1184-91. [PMID: 25868476 PMCID: PMC4514326 DOI: 10.1080/21645515.2015.1017694] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2014] [Revised: 01/25/2015] [Accepted: 02/06/2015] [Indexed: 11/10/2022] Open
Abstract
Analysis of medically attended injection site events data provides a vehicle to appreciate the inadequacies of vaccination practice for deltoid intramuscular injection and to develop best practice procedures. These data can be divided into 3 groups; nerve palsies, musculoskeletal injuries and cutaneous reactions and reflect inappropriate site of injection, needle over or under penetration, local sepsis and vascular complications. The aim of this review is to formulate best vaccination practice procedures for deltoid intramuscular injection of vaccines through the collation and analysis of medically attended injection site events.
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Affiliation(s)
- Ian F Cook
- University of Newcastle; Newcastle, New South Wales, Australia
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Al-Hassani F, Amin K, Lo S. Burns from acetylene gas: more than skin deep. BMJ Case Rep 2014; 2014:bcr-2013-200007. [PMID: 24842344 DOI: 10.1136/bcr-2013-200007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
Oxyacetylene welding torches are commonly used in industry, yet serious burns are fortunately rare. When dealing with the sequelae of these burn injuries, one must be aware of the high pressure component of these flame burns, which can penetrate and dissect the subcutaneous tissue. Appropriate initial assessment and preoperative planning are, therefore, essential to exclude and identify problems such as, compartment syndrome, subcutaneous emphysema and acute carpal tunnel syndrome. We present a case in which an innocuous palmar burn revealed a penetrating flame injury into the carpal tunnel.
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Affiliation(s)
- Fawaz Al-Hassani
- Department of Plastic Surgery, Queen Victoria Hospital, East Grinstead, UK
| | - Kavit Amin
- Department of Plastic Surgery, Royal Free Hospital, Surrey, UK
| | - Steven Lo
- Queen Victoria Hospital, East Grinstead, UK
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Jeavons RP, Dowen D, Rushton PRP, Chambers S, O'Brien S. Management of significant and widespread, acute subcutaneous emphysema: should we manage surgically or conservatively? J Emerg Med 2013; 46:21-7. [PMID: 24188603 DOI: 10.1016/j.jemermed.2013.08.051] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2012] [Revised: 07/21/2013] [Accepted: 08/15/2013] [Indexed: 10/26/2022]
Abstract
BACKGROUND Subcutaneous emphysema of a limb after acute injury is classically associated with gas gangrene. Delayed management can result in amputation and death. Typically caused by a clostridial infection, patients are unwell, with rapidly spreading clinical signs, abnormal laboratory results, and cultures positive. There are reports of widespread subcutaneous emphysema of a limb in well-appearing patients, with blood parameters within normal limits; however, the optimum management of this type of case is unclear. OBJECTIVE Our objectives were to present 4 new cases of acute subcutaneous emphysema in well-appearing patients managed with early surgery, review the literature, and discuss the management decisions in cases of acute subcutaneous emphysema in clinically well patients. CASE REPORTS Here we present a case series of 4 patients, all with penetrating injuries to the upper limb resulting in widespread subcutaneous emphysema within 24 h of injury. Mean age was 33 years. All were fit and well, with the exception of one with type 1 diabetes, no cardiorespiratory compromise, and no significant derangement of laboratory investigations. X-ray studies showed widespread gas within the soft tissues. All were treated aggressively with immediate surgical fasciotomy of the upper limb, thorough debridement, and washout as required. Gram stains revealed pus cells (polymorphonuclear leucocytes) in all, but organisms in only one case (Gram-positive cocci and bacilli). Prolonged culture grew organisms in all. All patients had a second washout and closure plus 6 weeks of antibiotics. All survived and had fully functioning limbs. Why should an emergency physician be aware of this? We recommend having a low threshold for rapid referral to an appropriate surgical speciality, allowing prompt and radical surgical management of this type of presentation, even in the presence of a well patient.
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Affiliation(s)
- Richard P Jeavons
- Department of Trauma and Orthopaedics, Sunderland Royal Hospital, Sunderland, England
| | - Daniel Dowen
- Department of Trauma and Orthopaedics, Sunderland Royal Hospital, Sunderland, England
| | - Paul R P Rushton
- Department of Trauma and Orthopaedics, Royal Victoria Infirmary, Newcastle upon Tyne, England
| | - Simon Chambers
- Department of Trauma and Orthopaedics, Sunderland Royal Hospital, Sunderland, England
| | - Shaun O'Brien
- Department of Trauma and Orthopaedics, Sunderland Royal Hospital, Sunderland, England
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Abstract
Benign subcutaneous emphysema is a rare clinical entity, documented by only a small collection of case reports. The presence of crepitus on physical examination and subcutaneous gas on radiographs is concerning for necrotizing fasciitis. Necrotizing fasciitis is a dangerous and deadly infection accounting for 500 to 1000 cases annually in the United States, with mortality rates of up to 76%. Delay in surgical treatment is related to increased morbidity and mortality; therefore, a high clinical suspicion should be maintained in patients with subcutaneous emphysema and/or crepitus. It is critical to recognize that no laboratory result or radiologic finding should delay surgical intervention if a high clinical suspicion for necrotizing fasciitis exists. However, not all subcutaneous emphysema represents a life-threatening infection. This article presents a case of benign subcutaneous emphysema treated with close observation and prophylactic antibiotics. Patients with necrotizing fasciitis typically appear ill and have the triad of swelling, erythema, and disproportionate pain. Patients who are not systemically ill and have minimal pain, no significant inflammatory changes at the site of crepitus, and stable hemodynamic parameters can be treated conservatively, with the caveat that close clinical monitoring is essential to avoid the unnecessary morbidity and mortality that can result from delaying intervention in the case of necrotizing fasciitis.
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[Benign subcutaneous emphysema after nail penetration. Case report and important differential diagnoses]. Unfallchirurg 2013; 117:174-8. [PMID: 23703620 DOI: 10.1007/s00113-013-2363-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
Crepitus under the skin after penetrating injuries: harmless benign subcutaneous emphysema or life-threatening infection with gas-producing bacteria (gas gangrene because of Clostridium perfringens, crepitating cellulitis because of anaerobic Streptococcus or other coliforme bacteria)? We report a case of a 74-year-old male who developed massive crepitation of the left upper extremity and the lateral thoracic wall and mediastinal emphysema after sustaining a laceration of the left thumb and forefinger from a nail. Because there was the suspicion of gas gangrene we performed generous skin incisions of the ventral and dorsal part of the hand, the forearm and upper arm and open wound treatment. A triple antibiotic therapy was initiated. Due to fast regression of the subcutaneous emphysema and the mediastinal emphysema, continuing lack of symptoms, negative smear test results from the beginning and low infection parameters in the blood all wounds could be closed 9 days after primary surgery. The suspicion of gas gangrene was not confirmed so the diagnosis of benign subcutaneous emphysema was made.
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Raeven P, Haagen AAM, de Hoog DENM. Non-infectious subcutaneous emphysema of the forearm in a 12-year-old schoolgirl. J Hand Surg Eur Vol 2009; 34:691-2. [PMID: 19959452 DOI: 10.1177/1753193408104562] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Affiliation(s)
- P. Raeven
- Department of General Surgery and Department of Paediatrics, VieCuri Medical Centre, Venlo, The Netherland
| | - A. A. M. Haagen
- Department of General Surgery and Department of Paediatrics, VieCuri Medical Centre, Venlo, The Netherland
| | - D. E. N. M. de Hoog
- Department of General Surgery and Department of Paediatrics, VieCuri Medical Centre, Venlo, The Netherland
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Tiong W, Butt F. Subcutaneous emphysema of the upper extremity following penetrating blackthorn injury to the wrist. J Plast Reconstr Aesthet Surg 2009; 62:e29-32. [PMID: 19177641 DOI: 10.1016/j.bjps.2007.11.002] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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