Subcutaneous Emphysema of the Lower Extremity of Gastrointestinal Origin" Report of a Case* ROBERT F. PICKELS, M.D.,]" ALLASTAIR M. KARMODY, M.B., CH.M., F.R.C.S., + MA~IS J. TSAPOOAS, M.D.,w PAUL GRIFFIN, M.D. 82 From the Departments of Surgery and Medicine, Albany Medical College of Union University, and the Veterans Administration Hospital, Albany, New York SUBCUTANEOUS EMPHYSEMA Of the lower extremity is usually a result of infection of the limb by gas-forming organisms. Gas spreading to the lower limb from elsewhere occurs only rarely. One such case, which was the cause of considerable diagnostic and therapeutic difficulty, is reported here. Report of a Case The patient, a 76-year-old diabetic man, was first seen in the outpatient department of the Albany Veterans Administration Hospital complaining of severe back pain of ten days' duration. Physical examination disclosed no abnormality, and x-rays revealed moderately severe arthritic changes of the lumbosacral region and spina bifida occulta. The latter was thought to be the cause of the pain, but it was noted that the leukocyte count was elevated to 14,000. Oral analgesics were prescribed and the patient was instructed to rest in bed pending an early appointment to the orthopedic clinic. There were no gastrointestinal symptoms at that time. Five days later the patient returned to the hospital in the early hours of the morning because of severe and steadily increasing pain in the left hip, pri- marily localized over the area of the greater trochanter. Physical examination disclosed that the left thigh had a mottled blue color, and was firm, * Received for publication February 12, 1973. ~-Former Chief Resident in Surgery. ~: Staff Surgeon, Assistant Professor of Surgery. w Chief of Surgery, VAH, Professor of Surgery. 82 Staff Physician, Assistant Professor of Medicine. Address reprint requests to: Dr. Robert F. Pickels, Staff Surgeon, U.S. Naval Hospital, Portsmouth, Va. 23708. 82 tender, and 5 cm larger than the right at the mid- thigh level (Figs. I and 2). There was pitting edema at the ankle. The femoral pulses were equal and easily felt, but no distal pulse was present in either limb. Movements of the left hip were ex- tremely painful. The abdomen was protuberant but not tender, and bowel sounds were present and normal. Rectal examination was negative. The temperature was 100F; the remainder of the clinical examination was unremarkable. The leukocyte count was 17,00~; x-rays of the chest and hip disclosed no abnormality. Because of the possibility of deep venous thrombosis, veno- grams of the lower Iimbs were obtained. These showed that the veins were normal, but on the films gas bubbles could be identified in the soft tissues of the thigh (Fig. 3). Arrangements were made for immediate exploration of the thigh, but within an hour there was a great increase in mottling and swelling, with obvious crepitation and blister formation extending circumferenetially from the inguinal ligament to the left knee. An x-ray of the thigh taken at that time showed gross gaseous infiltration (Fig. 4). As the patient's general condL tion was deteriorating rapidly, an open fasciotomy of the lateral aspect of the thigh was carried out from the greater trochanter to the Ieft knee. Much gas escaped through the incision, together with thin, brown, foul-smelling pus, and the muscles of the thigh appeared covered by purulent exudate, soft and necrotic. The findings at exploration strongly suggested that the infection arose beyond the confines of the thigh, and a tentative diagnosis of rupture of a psoas abscess into the thigh was made. Because of the rapidly deteriorating condi- tion of the patient, surgery could not be con- sidered, and it was hoped that the extensive incision of the thigh would allow free drainage of the purul- ent contents until such time as a more definitive procedure could be undertaken. However, because of the possibility that the infection was clostridial Dis. CoL & Rect. Volume 17 yan.-Feb. 1974 Number 1