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Case reports

@jury Vol. 29, No. 7, pp. 543-545, 1998 0 1998 Else&r Science Ltd. All rights reserved

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Crepitus following a dog bite

Paul Gill and David Lewis Queen Mary’s Hospital, Sidcup, Kent, UK

Injury, Vol. 29, No. 7, 543-545, 1998

Concerned, she attended our Accident and Emergency Department. On examination there was a single 5-mm puncture wound in the first web space of her right hand (Figure 1). The wound was clean with no discharge or surrounding erythema and was not malodorous. The dorsum of the hand and forearm up to the elbow were swollen. There was no erythema, warmth or skin necrosis evident but palpation did elicit crepitus consistent with surgical emphysema (Figure2). There was full painfree movement of the fingers and wrist with no distal neurovas- cular deficit. She had a temperature of 38°C but appeared systemically well with normal vital signs. Her white cell

Figure 1. Puncture wound in first web space.

Introduction The presence of crepitus following a dog bite leads to a high degree of suspicion of a gas forming infection which requires aggressive medical and surgical treat- ment. Although this diagnosis is generally straight- forward, there are occasions however, which this case illustrates, when a clinician may be misled.

Case report A 66-year-old Italian lady presented to our Accident and Emergency Department 6 h after being bitten by her pet Doberman dog which had recently been released from 6 months in quarantine. She had sustained a wound to the first web space of her right hand and as a first aid measure she soaked cotton wool balls in antiseptic and vigorously cleaned the wound. Four hours later she repeated the procedure using in total approximately 50 ml of the antiseptic. Fifteen minutes later her index finger began to swell, quickly followed by the back of her hand. Figure 2. Right hand and forearm swelling.

544 Injury: International Journal of the Care of the Injured Vol. 29, No. 7,1998

count on admission was 8.7 x 1o”A. Wound swabs and blood cultures were taken. Soft tissue radiographs demon- strated the presence of subcutaneous gas with no intra- muscular involvement (Figure3). She was admitted under the care of the General Surgeons with a suspected diagnosis of gas gangrene and she was commenced on intravenous Benzyl Penicillin, Flucloxacillin and Metronida- zole. She was fasted and referred to the orthopaedic team for consideration of surgical debridement and/or fasciotomy. On review she was now afebrile, her vital signs remained normal and a repeat white cell count was 6.4 x lO’/‘l. In the absence of systemic toxicity, local pain, tenderness or skin necrosis along with the history of rapid onset of surgical emphysema we felt that the diagnosis of

gas gangrene or necrotising fasciitis was extremely unlikely. She was questioned further as to the nature of the antiseptic used to clean the wound and at this time it was elicited that she had used in total approximately 50 ml of undiluted 6% hydrogen peroxide (Figurc4) and had actively squeezed the solution into the wound. As a precaution she was continued on intravenous antibiotics and kept in hospital for observation. She remained systemically well and both wound and blood cultures failed to demonstrate either anaerobic or aerobic organ- isms. The subcutaneous emphysema had begun to recede from her forearm and after 4 days had completely resolved and crepitus was impalpable. She was discharged with a short course of oral Augmentin.

Figure 3. Radiographs demonstrating subcutaneous gas in the hand and forearm.

Case reports 545

Figure 4. Antiseptic used by patient to clean wound.

Discussion The differential diagnosis of post traumatic peripheral surgical emphysema can be divided into infectious and non-infectious causes. The diagnosis of infectious surgical emphysema includes clostridial gas gangrene and necrotising fasciitis. Gas producing organisms such as certain types of streptococci and coliforms may occur without involvement of muscle’,3. These conditions can be rapidly fatal and early surgical debridement and fasciotomy are indicated. Non-infectious causes include accidental injection of compressed air, generation of gas by magnesium or metal oxides introduced into the

wound’, trapping of air by the wound acting as a one way valve”, and iatrogenic irrigation/injection of hydrogen peroxide”.h. In our case the patient had treated herself at home by using hydrogen peroxide as a disinfectant and squeezing the undiluted solution into the wound. This was clearly the cause of the surgical emphysema in this lady, this being ascertained from a careful history of the use of hydrogen peroxide, the rapid speed of onset of crepitus and an absence of any local erythema, tenderness, skin necrosis or systemic toxicity. Hence, a misdiagnosis of an infectious cause was avoided with its therapeutic implicationsThe production of surgical emphysema from self administration of hydrogen peroxide does not appear to have been previously reported in the literature.

References 1 Nichols R. L. and Smith J. W. Gas in the wound: what

does it mean? Surg Clin North America 1975; 55: 1403-1410.

2 Green R. J., Dafoe D. C. and Raffin T. A. Necrotising fasciitis. [RezTiew] Chest 1996; 110(l): 219-229.

3 Filler R. M., Griscom N. T. and Pappas A. Post traumatic crepitation falsely suggesting gas gangrene. New England Jour~~al of Medicine 1968; 278: 756-761.

4 Butt M. and Hird G. F. Surgical emphysema of the dorsum of the hand. Jour?lal cf Hand Surgery-British Volume 1990; 15(3): 379-380.

5 Friedman R. J. and Gumley G. J. Crepitation simulating gas gangrene. Journal of Bone ]oint Surgery [Am] 1985; 67(4): 646-647.

6 Johnson N. Fournier’s gangrene and crepitus in the perineum. British Journal of Clinical Practice 1990; 44(7): 293.

Paper accepted 23 March 1998.

Requests for reprints should be addressed to: Mr P. Gill, Treetops, Clock House Lane, Sevenoaks, Kent, TN13 3HG, UK.