Jul 1, 1998 - painful right leg and great toe. On presentation she was clinically well. There wasa small puncture wound over her right metatarsophalangeal ...
Ann R Coll Surg Engl 1999; 81: 115-116
CASE REPORT
Sucking in jury or gas gangrene? A B Williams BSc FRCS*
N 0 Aston MChir FRCS
Registrar in General Surgery
Consultant Surgeon
Greenwich District Hospital, London
Key words: Surgical emphysema; Gas gangrene; Sucking wounds
There are many causes of surgical subcutaneous emphysema. The most serious of these is gas gangrene. However, small puncture wounds may also cause this sign owing to a one-way valve being formed with the skin. This paper sets out to define the criteria for a sucking wound and suggest a management regimen.
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Case report An 88-year-old non-diabetic woman was admitted from the accident and emergency department complaining of a painful right leg and great toe. On presentation she was clinically well. There was a small puncture wound over her right metatarsophalangeal joint of the great toe. There was gross surgical emphysema of the leg to just above the knee. No cellulitis was present. The leg was only mildly tender. She was apyrexial and had a normal white blood count (6.99x 109/1). Plain radiographs of the leg confirmed surgical emphysema limited to the subcutaneous tissues and not involving the muscles of the leg (Fig. 1). Staphylococcus aureus was grown from swabs taken of the puncture site. The management consisted of intravenous antibiotics, leg elevation and inhaled oxygen, and the patient made an uncomplicated recovery. Repeat radiographs at 2 weeks demonstrated full resolution of the emphysema.
Discussion Subcutaneous surgical emphysema has many causes. Traumatic pneumothorax, barotrauma and perforation of any part of the gastrointestinal tract can cause air to *Present appointment: Registrar in General Surgery, Bromley District Hospital Correspondence to: Mr N 0 Aston, Consultant Surgeon, Greenwich District Hospital, Vanbrugh Hill, Greenwich, London SE10 9HE
Figure 1. Radiograph of lower limbs showing subcutaneous emphysema in the right lower limb; note the absence of myositis.
track to the subcutaneous tissues (1). Non-clostridial gasforming organisms can cause subcutaneous gas formation and must be suspected in the diabetic patient (2). The most sinister cause of subcutaneous emphysema is gas gangrene. Clostridial infections must be considered and, if present, treated rapidly and aggressively to prevent death.
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A B Williams and N 0 Aston
Surgical emphysema may be self-induced, or related to a sucking injury of a limb, as is suspected in the case reported. There have been several reports of such injuries in the literature involving both upper and lower limbs (35). The proposed mechanism for the emphysema is that a small defect/breach in the skin acts as a flap valve, allowing air to be sucked into the superficial tissues by the negative pressure created by movement. In establishing a diagnosis of a sucking wound causing emphysema the following points must be noted: 1 Exclusion of clostridial infection. 2 Absence of pyrexia, tachycardia, shock or leucocytosis. 3 Presence of a puncture site situated over/at a joint involved in repetitive movement. 4 The radiograph must demonstrate emphysema confined to the subcutaneous or interfascial planes without myositis (thus excluding gas gangrene). 5 The emphysema usually develops rapidly after the injury (whereas gas in the tissues from clostridial infection occurs at around 18 h after injury.)
The treatment for this condition should be essentially rest and elevation of the affected limb. The authors advocate the use of broad-spectrum antibiotics to cover Gram-positive and Gram-negative bacteria and also anaerobes. While antibiotics are strictly not indicated, we recommend their use as a sensible precaution.
References 1 Hopkins RL, Hamre M, Davis SD, Bonis SL, Frieberg EM. Spontaneous subcutaneous emphysema. Am J Emerg Med 1994; 12: 463-5. 2 Davis JM, Kugler G, Nixon BP. Nonclostridial cellulitis with subcutaneous emphysema. J Foot Surg 1992; 31: 85-7. 3 Stevenson J. Sucking wounds of the limbs. Injury 1995; 26: 151-3. 4 Hamilton S, Towers MJ, Pegum JM. Pneumomediastinum due to a sucking wound of the knee. AJR 1989; 152: 1131-2. 5 Wallace MF, Mackie IG, Dickinson IC. A nonbacterial cause of post-traumatic soft-tissue gas. J Trauma 1988; 28: 254-5. Received 1 July 1998
