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Emerg Med J. 2007 November; 24(11): 798–799.
PMCID: PMC2658337

Benign surgical emphysema of the hand and upper limb: gas is not always gangrene—a report of two cases


Subcutaneous emphysema of the hand can result from benign causes. Differentiating this from emphysema caused by gas‐forming organisms is essential in the acute stages of presentation as the management differs considerably. We present two cases of benign surgical emphysema and highlight the importance of distinguishing between this and gas gangrene. A considered history and the absence of systemic features associated with benign causes of subcutaneous air will prevent unnecessary surgical exploration.

Benign subcutaneous emphysema of the hand and upper limb of non‐infectious aetiology has been documented in several case reports.1,2,3 Correct diagnosis in the accident and emergency department will avoid the unnecessary surgical exploration for a benign condition. Subcutaneous emphysema of benign aetiology is not associated with other symptoms and the patient is systemically well. It has been reported as a result of high pressure injury from power tools, minor puncture wounds creating a one way valve mechanism, airgun injury, and surgical procedures to the hand. The following cases highlight the importance of careful concise knowledge of the history, absence of systemic features, as well as regarding specific signs such as crepitus in the context of other signs and symptoms and not in isolation.

Case 1

A healthy 40‐year‐old right handed woman sustained a puncture wound in the first web space of her left hand with the tip of a clean kitchen knife. She presented to the accident and emergency department 8 h after the injury complaining of a swollen left hand and no other symptoms.

She was afebrile and non‐tachycardic. There was minor localised redness at the wound site and crepitus palpable throughout the dorsal and volar compartments of the hand, extending to the wrist. The white cell count (WCC) was normal and subsequent blood cultures were negative. Radiographs of the hand revealed air in the subcutaneous tissues (fig 1A1A).

figure em46755.f1
Figure 1 (A) Anteroposterior (AP) and oblique radiograph of the left hand in case 1 showing gas in the subcutaneous tissues. (B) AP radiograph of the left hand and forearm in case 2 showing gas in the subcutaneous tissues.

She was treated conservatively with elevation and intravenous antibiotics, remained well, and was discharged home the next day.

Case 2

A healthy 19‐year‐old right handed labourer sustained a puncture wound to the dorsum of his left hand with a metal spike 1 month before presentation. He attended our accident and emergency department with a 24 h history of gradual swelling, redness and increasing pain at the site of original injury.

He was afebrile and non‐tachycardic. There was localised erythema at the wound site and crepitus palpable throughout the dorsum of his left hand, extending proximally to the mid forearm level. The WCC and C reactive protein (CRP) were normal and subsequent blood cultures were negative. Radiographs of the hand and forearm revealed air in the subcutaneous tissues (fig 1B1B).

A decision for surgical exploration was made. Operative findings showed no evidence of infection or necrotic tissue and muscles appeared healthy. He remained at all times systemically well with a normal WCC and negative blood cultures. He was discharged home 48 h after initial presentation.


Subcutaneous emphysema affecting an isolated limb is rare and not all subcutaneous air in the hand or upper limb signifies a life threatening infection. It is important to differentiate benign conditions in the acute setting of accident and emergency from gas gangrene (clostridial myonecrosis) or crepitant infection caused by other gas‐forming bacteria, such as anaerobic streptococci and some coliform bacteria.1

Butt and colleagues3 describe a case of surgical emphysema of the hand treated only with antibiotics, and Filler et al2 reported an additional three cases, all of which were successfully managed conservatively. Both groups point out that infection from gas‐forming organisms usually takes 12–18 h to develop and that gas in the subcutaneous tissue within 6–10 h of trauma is most likely to be indicative of a benign process.

In the two cases presented here, there was a history of injury with the patient remaining well at all times. Inflammatory indices were normal, and a mechanical one way valve mechanism for the accumulation of air in the subcutaneous tissue was the most likely explanation. Under such circumstances, it is acceptable to reassure the patient and discharge on oral antibiotics with an outpatient follow up appointment. Conservative treatment has been suggested for subcutaneous emphysema in patients who are systemically well, with minimal pain at the site of injury and in the absence of extensive cellulites.1,4


Benign causes of subcutaneous emphysema should be considered in patients presenting without any signs and symptoms of an infectious process or systemic illness. This will avoid the unnecessary aggressive treatment for a benign condition which is reserved for gas gangrene.


Competing interests: None declared.


1. Mink van der Molen A B, Birndorf M, Dzwierzynski W W. et al Subcutaneous tissue emphysema of the hand secondary to non‐infectious aetiology: a report of two cases. J Hand Surg 1999. 24A638–641.641 [PubMed]
2. Filler R M, Griscom N T, Pappas A. Post‐traumatic crepitation falsely suggesting gas gangrene. N Engl J Med 1968. 278758–761.761 [PubMed]
3. Butt M, Hird G F. Surgical emphysema of the dorsum of the hand. J Hand Surg 1990. 15B379–380.380 [PubMed]
4. Ozalay M, Akpinar S, Hersekli M A. et al Benign non‐infectious subcutaneous emphysema of the hand. Arch Orthop Trauma Surg 2003. 203433–435.435 [PubMed]

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