IN BRIEF
Noninfectious Subcutaneous Emphysema of the
Upper Extremity
Jacob A. Mack, BS, Shoshana L. Woo, MD, Steven C. Haase, MD
C
REPITUS CAUSED BY SUBCUTANEOUS emphysema
in the upper extremity can be alarming for
necrotizing fasciitis or gas gangrene, a rapidly
progressing infection of the subcutaneous tissue and
deep fascia with high morbidity and mortality.1
However, noninfectious etiologies exist and must be
promptly recognized to avoid unnecessary surgery.
The distinction is critical: Whereas the misdiagnosis
of necrotizing fasciitis in noninfectious cases can lead
to unnecessary surgery, the neglect of true necro-
tizing fasciitis can result in limb amputation or death.
This review describes the various etiologies, workup
and diagnosis, and general guidelines for management
of noninfectious subcutaneous emphysema of the up-
per extremity. A total of 67 cases have been reported in
the English scientific literature (Table 1), a minority of
which were reported in hand surgery journals.
ETIOLOGY
A commonly reported cause of noninfectious upper
extremity subcutaneous emphysema is the injection of
air or inert gas (Table 1). Such cases have involved
compressed air tools, a football inflation pump, scuba
diving equipment, an air rifle, a mishap during blood
donation, and factitious manipulations related to Mün-
chausen syndrome.
A small hand or wrist laceration or puncture wound
can also lead to crepitus by serving as a one-way valve
for airflow into the soft tissues. The mechanism was
first proposed by Kemp2 and later demonstrated in
cadavers by Brummelkamp.3 In the presence of a web
From the University of Michigan Medical School; and the Section of Plastic Surgery,
Department of Surgery, University of Michigan Health System, Ann Arbor, MI.
Received for publication January 28, 2015; accepted in revised form March 5, 2015.
No benefits in any form have been received or will be received related directly or
indirectly to the subject of this article.
Corresponding author: Steven C. Haase, MD, Section of Plastic Surgery, Department of
Surgery, University of Michigan Health System, 2130 Taubman Center, 1500 E Medical
Center Drive, Ann Arbor, MI 48109; e-mail: shaase@med.umich.edu.
0363-5023/15/4006-0031$36.00/0
http://dx.doi.org/10.1016/j.jhsa.2015.03.012
Ó 2015 ASSH
space puncture wound, for example, digital abduction
and adduction produce negative pressure, drawing air
into the subcutaneous space; the air is then trapped
as the wound collapses. Repetitive motion can thus
lead to progressive subcutaneous air accumulation.
This mechanism has been corroborated by others,4e6
and such injuries have been referred to as “sucking
wounds” of the limbs.7
Another cause of noninfectious subcutaneous em-
physema is the accidental or deliberate injection of
chemical substances. Reported cases have involved
the use of magnesium alloy powder by machinists,
hydrogen peroxide during wound cleansing, hexa-
fluoroethane (Freon) used to manufacture athletic
shoes, natural gas from a ruptured gas line, and n-
hexane spot remover fluid in an attempted suicide.
Pulmonary events related to pneumomediastinum,
pneumothorax, and ventilator use have also been asso-
ciated with upper extremity subcutaneous emphysema.
Surgical causes have been reported as well in the form of
molar extraction, joint mobilization exercises after
elbow arthroscopy, and the malfunction of a suction
drain after wrist ganglion cyst removal.
In Brief
CLINICAL PRESENTATION
Generally, patients with noninfectious subcutane-
ous emphysema are devoid of systemic symptoms
(Table 2). Crepitus develops within minutes to hours
after injury and pain is mild to moderate. In contrast,
patients with necrotizing fasciitis are febrile and often
appear toxic, and crepitus appears at least 12 hours
after injury. Disproportionate pain is the most sensi-
tive sign and often the first one of necrotizing fasciitis
(Table 2).
DIAGNOSTIC TESTS
Radiological studies may be helpful for the diag-
nosis, provided that they do not delay treatment.
Plain radiographs can be rapidly obtained. In
noninfectious cases, air is seen to respect the tissue
planes (Fig. 1). In gas gangrene, air can be seen to
r Published by Elsevier, Inc. All rights reserved. r 1233
 1234 NONINFECTIOUS SUBCUTANEOUS EMPHYSEMA

TABLE 1. Reported Etiologies of Noninfectious Subcutaneous Emphysema in the Upper Extremity

Etiology n (%) Reference

Air or inert gas injection 25 (37) 4, 10e23

Laceration or puncture 25 (37) 3e7, 9, 24e30
Chemical injection 10 (15) 4, 31e35
Pulmonary event 4 (6) 4, 36
Surgical complication 3 (5) 4, 37
Total 67

TABLE 2. Criteria to Differentiate Subcutaneous Emphysema From Necrotizing Fasciitis and Noninfectious
Etiologies
Criterion Necrotizing Fasciitis Noninfectious Etiologies Reference

Clinical signs Toxemia, fever, chills, hypotension, No signs of sepsis or toxemia. No 1, 4e6, 38
tachycardia, swelling, erythema, signs of vascular, sensory, or motor
disproportionately severe pain, tense deficits. Crepitus, tenderness,
edema, bullae, purplish skin swelling, and erythema may be
discoloration, crepitus, sensory and present.
motor deficits, altered mental status
Timing  12e18 h until onset of clinically  6 h to produce clinically significant 6, 24
significant crepitus crepitus
Leukocytes > 15.4  109/L Within normal limits 38
Serum sodium < 135 mmol/L Within normal limits 38
Blood urea nitrogen > 15 mg/dL Within normal limits 39
Magnetic resonance Fascial inflammation appears as low e 8
imaging T1/high T2 signals; necrosis
detected by absence of gadolinium
enhancement
X-ray Gas within muscle bundles, with Gas limited to loose soft tissues 24
edema of overlying skin and external to muscles and deep fascia;
In Brief

superficial soft tissues fat shadows and skin-fat

Computed tomography
scan
Tissue biopsy
Laboratory Risk Indicator
for Necrotizing Fasciitis
score (see Table 3)
differentiation are well preserved
Asymmetrical fascial thickening with 40
fat stranding and presence of gas
Cultures and Gram stains are positive Cultures, Gram stains, and biopsies 5, 41, 42
for polymicrobial infection are negative for necrotizing
infection
6 <6 1, 5

invade the muscle bundles and therefore dissect muscle
fibers (Table 2).
Magnetic resonance imaging should be reserved for
select cases in which the patient has a mixed clinical
presentation but is otherwise hemodynamically stable,
and in which the suspicion for necrotizing fasciitis is
generally low. Treatment of suspected necrotizing
infection should never be delayed to obtain a magnetic
resonance image.
Inflammatory markers in noninfectious cases are
usually within normal limits.4 The Laboratory Risk
Indicator for Necrotizing Fasciitis may be helpful in
determining whether a necrotizing infection is
present.1,5 It has a high sensitivity (95%) and low
specificity (40%) in these situations (see Table 3 for
algorithm and references).
A Gram stain of the wound surface can be obtai-
ned urgently but can be misleading if contaminated

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 NONINFECTIOUS SUBCUTANEOUS EMPHYSEMA 1235

TABLE 3. Laboratory Risk Indicator for

Necrotizing Fasciitis
Laboratory Value Range Points

C-reactive protein, mg/L < 150 0

 150 4
Leukocyte, mL < 15,000 0
15,000e25,000 1
 25,000 2
Hemoglobin, g/dL > 13.5 0
11e13.5 1
< 11 2
Sodium, mmol/L  135 0
< 135 2
Creatinine, mg/dL  1.6 0
> 1.6 2
Glucose, mg/dL  180 0
> 180 1
Total score
Necrotizing soft tissue infection 6
Not necrotizing soft tissue infection <6

A sum of points  6 correlates with necrotizing soft tissue

FIGURE 1: Lateral view of the left upper extremity demon-
strating subcutaneous air from the hand extending beyond the
elbow. As is typical of noninfectious subcutaneous emphysema,
the air remains above the muscular fascia, with no evidence of
intramuscular invasion.
by skin flora. By contrast, one of the most useful tests
may be an intraoperative Gram stain for bacteria in
infection.43,44
conservative treatment, as documented in the litera-
ture. Broad-spectrum antibiotics are recommended
until the diagnosis of noninfectious emphysema be-
comes certain based on one’s clinical assessment of the
patient, as explained above.5,8,9 Maintaining broad-

the deeper tissues.
Preoperative or intraoperative tissue cultures can aid
in identifying invasive pathogens, but they may take
several hours to days for results. However, they may be
helpful in narrowing the patient’s initially broad anti-
biotic regimen once results are available. At the time of
deep tissue cultures, tissue biopsies for anatomic pa-
thology should also be taken. These biopsies may yield
additional information to help establish a diagnosis in
atypical injuries or infections.
TREATMENT
Once diagnosed appropriately, noninfectious subcu-
taneous emphysema of the upper extremity can be
treated effectively with close observation. Specifically,
serial examinations, limb elevation to reduce swelling,
orthosis immobilization to prevent further air entry
and entrapment, and prophylactic broad-spectrum
antibiotics targeting group A Streptococcus, gram-
negative bacteria, anaerobes, and methicillin-resistant
Staphylococcus aureus have been the mainstay of
In Brief
spectrum antibiotics is reasonable until cultures, if
obtained, return negative. Conferring with the infec-
tious disease team regarding an appropriate regimen
would be helpful in most cases.
In our review of 67 noninfectious cases reported in the
literature, 47 (70%) were treated with close observation.
On average, crepitus resolved within 4.5  7.1 days.
Twenty cases (30%) were treated surgically. Four of
these (20%) were for concomitant injury, 2 (10%) were
for foreign body removal, and 1 (5%) was for chemical
washout. The remaining 13 surgeries (65%) were
deemed unnecessary; that is, surgery was conducted
under the suspicion of an infection but no signs of
infection were present intraoperatively or on subse-
quent tissue cultures.
Accurately distinguishing between noninfectious
and infectious causes of upper extremity subcutaneous
emphysema is critical for optimizing patient outcomes
and minimizing morbidity and mortality. In cases of
diagnostic uncertainty, rapid surgical intervention is
advised because delays in the treatment of necrotizing

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 1236 NONINFECTIOUS SUBCUTANEOUS EMPHYSEMA
fasciitis can result in devastating consequences, inclu-
ding death. Based on review of the literature, we suggest
that if the diagnosis remains equivocal, an initial surgi-
cal approach using small limited incisions can be useful
in determining the clinical presence of a necrotizing
infection before proceeding with larger incisions or
more radical procedures.
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