An Unusual Cause for Noninfectious Subcutaneous Emphysema of the Upper Extremity

Subcutaneous emphysema after trauma should raise immediate suspicion for a necrotizing soft-tissue infection. However, there are certain circumstances in which subcutaneous emphysema is the result of a benign or noninfectious process. In the literature, subcutaneous emphysema has been reported secondary to high-pressure injection injuries, factitious self-injection of air and chemical substances in the extremities, elbow arthroscopy, air-sucking phenomenon from traumatic lacerations, and iatrogenic use of hydrogen peroxide in the face and extremities1-13. Surgical evaluation should be obtained for the assessment of subcutaneous emphysema so that, if necessary, immediate surgical intervention can be performed. We report a case of noninfectious subcutaneous emphysema of the upper extremity with an unusual cause. The patient was informed that data concerning the case would be submitted for publication, and she provided consent. A forty-six-year-old right-hand-dominant woman fell on some ice and landed on the left elbow, causing a 2-cm laceration over the olecranon process. The patient reported that she initially had managed the wound with intermittent hydrogen peroxide irrigation and gauze dressing. She was a medical assistant for a primary care physician who evaluated the wound at work approximately twelve hours after the initial injury. At that time, she had not experienced any symptoms in the upper extremity except for localized pain around the wound. She continued to work with a sterile dressing over the wound, but did not have the wound closed. Approximately twenty-four hours after the fall, she presented to our emergency room with the symptom of subjective pain (rated 5 of 10) in the entire upper extremity, especially with elbow range of motion. She also described a “crunchy” feeling in the forearm that had worsened over the course of the day and copious drainage from the laceration site. She denied numbness or tingling distally and any systemic symptoms …