LETTER TO THE EDITOR
Non-infective bilateral upper limb subcutaneous emphysema
following elbow trauma
Ian C. C. King
Tom H. McKinnell
Ian A. Forrest
Sahan V. Rannan-Eliya
Received: 20 October 2014 /Accepted: 14 December 2014 / Published online: 13 January 2015
Springer-Verlag Berlin Heidelberg 2015
Subcutaneous emphysema of a limb typically raises the sus-
picion of gas gangrene or necrotising fasciitis. Its presence
without an infective origin in one extremity is rare [1–9];
presentation in both upper limbs has never been reported.
A 70-year-old lady presented with a one-week history of
painless bilateral forearm swelling. The patient had fallen
3 weeks previously grazing both elbows on her carpet. Due
to no functional impairment, nor obvious bony injury, she
managed the small abrasions on each elbow herself and ini-
tially sought no medical assistance. Having presented to her
general practitioner (GP) with the swelling, she was informed
she had ‘gas under the skin’.
Past medical history included asthma treated with long-
term steroids. She lived alone and was entirely self-caring. She
was a keen knitter during which she routinely rested her
elbows on her armchair.
Examination revealed symmetrical forearms with two
small skin openings overlying both olecranons (Fig. 1).
With elbow flexion, these holes discharged a frothy fluid
(Fig. 1). There was no evidence of pus or infection.
Palpation showed normothermic limbs with non-tender
crepitus and soft forearm compartments. Movements
throughout the upper limb were entirely normal and
Radiographs of both forearms demonstrated extensive sub-
cutaneous free gas (Figs. 2 and 3), distal to the elbows. No
pneumothorax was seen on plain chest radiograph. Haemato-
logical investigations, including inflammatory markers, were
entirely unremarkable, and swabs of the elbow discharge
showed pus cells but no microbial growth.
In a systemically well patient, with no signs of infection or
tissue compromise, immediate extensive and destructive sur-
gical intervention seemed inappropriate. This patient was
managed conservatively with dry dressings over the openings
and a compressive bandage. Prophylactic antibiotics were
considered unnecessary: the wounds were already a month
old, and the swabs had grown no organisms.
I. C. C. King (*)
T. H. McKinnell
I. A. Forrest
S. V. Rannan-Eliya
Royal Victoria Infirmary, Newcastle upon Tyne NE1 4LP, UK
I. C. C. King
Queen Victoria Hospital, East Grinstead RH19 3DZ, UK
Eur J Plast Surg (2015) 38:341–344