Injury: the British Journal of Accident Surgery (1991) Vol. 22/No. 2 163

dine) which produces the double advantage of a local action on the capillary circulation preventing thrombosis and clotting of the blood leaking from the trefoil wound for a further so--90 min (Foucher et al., 1981).

The use of the leech in plastic surgery is well recognized. It has been described as a venous decongestant for tubed pedicles and flaps (Derganc and Zdravic, 1960; Batchelor et al., 1984; Rao et al., 1985), for periorbital hematomata (Bunker, 1981), in distal digital replantation (Foucher et al., 1981), in revascularized scalps as a decongestant (Hender- son et al., 1983) and in replanted pinnae with inadequate venous drainage (Mutimer et al., 1987).

In the cases presented here, leeches were used for prolonged periods to treat venous congestion, which in time compromises arterial entry, in an attempt to preserve the maximal amount of irreplacable specialized skin. Distally based plantar avulsions often necrose, and in these two cases there was a strong clinical impression that the leeches saved as much as 60 per cent of plantar skin in the first case and 85 per cent in the second case.

Both patients were placed on broad spectrum antirnicro- bials as prophylaxis against infection initially, and subse- quently because of the risk of leech-induced Aeromonas hydrophila (Whitlock et al., 1983; Dickson et al., 1984; Mercer et al., 1987; Hermansdorfer et al., 1988).

References

Batchelor A. G. G., Davison P. and Sully L. (1984) The salvage of congested skin flaps by the application of leeches. Br. J, P&X& surg. 37,358.

Bunker T. D. (1981) The contemporary use of the medicinal leech. Itijuy 12, 11.

Derganc M. and Zdravic F. (1960) Venous congestion of flaps treated by the application of leeches. Br. 1. Plast Surge 13,187.

Dickson W. A., Boothman P. and Hare K. (1984) An unusual source of hospital wound infection. Br. Med J. 289,1727.

Foucher G., Henderson H., Maneau M. et al. (1981) Distal digital replantation. Int. 1. Micr~surg. 3,263.

Henderson H. P., Matti B., Laing A. G. et al. (1983) Avulsion of the scalp treated by microvasculz repair: the use of leeches for post-operative decongestion. Br. J. Pkzt. Surg. 36,235.

Hermansdorfer J., Lineaweaver W., Follansbee S. et al. (1988) Antibiotic sensitivities of Aeromonus Hydrophila cultured from medicinal leeches. Br. ]. Plasf. Strrg. 41,649.

Mercer N. S. G., Beere D. M., Bomemisza A. J. et al (1987) M&&al leeches as sources of wound infection. Br. Med. ]. 294,937.

Mutiier K. L., Banis J. C. and Upton J. (1987) Microsurgical reattachment of totally amputated ears. Plasf. Reconstr. %g. 79, 535.

Rao P., Bailie F. B. and Bailey B. N. (1985) Lee&mar& in microsurgery. Pradiiiow 229,901.

Whitlock M. R., O’Hare P. M., Saunders R. et al. (1983) The medicinal leech and its use in plastic surgery. Br. J Phsf. Sqq. 36, 240.

Young M. A. (1984) Bleeding Antiques Part 3, Leeching. Antique collecting 19‘27.

Paper accepted 9 August 1990.

Requests for reprink shacld be ad&es.& to: P. J. Regan PRCSI, Department of Plastic and Reconstructive Surgery, Stoke Mande- ville Hospital, Mandeville Road, Aylesbury, Buckinghamshire HP21 SAL, UK.

A high-pressure air injection injury

B. Olesen and P. V. Madsen Esbjerg County Hospital, Esbjerg, Denmark

Since 1937 several injection injuries mainly due to paint and grease guns have been reported (Kaufman, 1970; Gelberman et al., 1975; Dickson, 1976; Schoo et al., 1980). A few injection injuries of hands and fingers with compressed air have been reported (Wells, 1976; Catania et al., 1980; Caspi et al., 1987). We report an accident with air injection into a leg resulting in subcutaneous emphysema, pneumoretro- peritoneum, pneumomediastinum and pneumopericardium.

Case report

In a fish plant, plastic bags were tested by air pressure. A compressor delivered air under a maximal pressure of 6 bars; a reduction valve reduced the pressure at the test cannula to 1 bar.

The accident happened when the cannula slipped out of the hand of a 30-year-old male worker and penetrated the skin of his right calf. He felt a sting in his calf followed by intense swelling of the whole leg. He immediately removed the cannula and was admitted to hospital within 15 min. He complained of pain in his

0020-1383/91/020163-02 0 1991 Butterworth-Heineman Ltd

right leg, aaoss the loins and upper abdomen. Pulse and blood pressure were normal. There was a 1 mm-long stab wound (10 cm proximal to the ankle on the medial aspect of the calf) and the extremity from foot to groin was swollen with gross subcu- taneous emphysema. No signs of compression were found. Radiographs showed interfascial air in the right leg, pneumo- retroperitoneum, pneumomediastinum and pneumopericardium (Figures 1-5). The patient stayed in hospital for 2.5 days. Mild analgesics were given and penicillin administered prophylactically for 6 days. The pain subsided in 1 week, while tiredness remained for another week. He resumed work and was fully fit.

Discussion

High-pressure injection of chemical agents results in wide- spread dispersion of toxic agents in the tissue, in&ding a severe inflammatory reaction, necrosis and thrombotic complications (Kaufman, 1970; Gelberman et al., 1975; Dickson, 1976; Schoo et al., 1980). The treatment will normally be radical excision of necrotic tissue and liberal fasciotomies.

164 Case reports

Figure 1. Injected air in the soft tissue, right foot.

High-pressure injection of gases results in other potenti- ally severe complications. Air embolism which may be lethal is a theoretical possibility, but has to our knowledge not been reported. Henderson and Hopson (1982) have described uncomplicated pneumoretroperitoneum and pneumoscrotum after knee arthroscopy when air was mixed accidentally with the saline used for the examination. Air injection into a hand resulting in subcutaneous emphysema of the upper limb, face, neck, trunk and scrotum without complications has been reported by Catania et al. (1980). The now obsolete presacral pneumography utilizes the fact that enough gas (1.5-3 litres) may be insufflated and tolerated retroperitonealiy to facilitate radiographic exam- ination of the adrenal glands (Saxton and Strickland, 1972). In the injury presented here the expansion of air was extreme and yet the patient had few symptoms. We have found no reports of complications such as compartment syndrome and cardiac tamponade. Poulton et al. (1986) in an animal experimental study conclude that isolated thoracic

Figure 2. Injected air in the right knee joint and between the muscles at the femur.

subcutaneous emphysema does not adversely affect cardio- pulmonary function during positive pressure ventilation.

Management of air injection injuries rarely requires surgical intervention, but should, in our opinion, include radiographs to establish the expansion of air, clinical observation (consider cardiac monitoring in case of pneumopericardium), symptomatic treatment and prophy- lactic antibiotics.

References

Caspi I., Lin E., Nerubay J. et al. (1987) Subcutaneous emphysema following high-pressure injection injury of inert gas. 1. Trauma 27, 1305.

Catania S., Pessina R., Sansonetti G. et al. (1980) LJn singolare case di enfisema sottocutaneo. Chir. Ital. 32,398.

Dickson R. A. (1976) High pressure injection injuries of the hand. A clinical, chemical and histological study. Hand 8, 189.

Gelberman R. H., Posch 1. L. and Jurist J. M. (1975) High pressure injection injuries of the hand. 1, Ebne]oint Surg. 57A, 935.

Henderson C. E. and Hopson C. N. (1982) Pneumoscrotum as a complication of arthroscopy. J Bone Joinf Swg. 64A, 1238.

Kaufman H. D. (1970) High pressure injection injuries, the problems, pathogenesis and management. k&d 2, 63.

Poulton T. J., Haldeman L. W. and Klein E. F. (1986) Cardiopul- monary effects of severe thoracic subcutaneous emphysema. 1. Trauma 26, 396.

Injury: the British Journal of Accident Surgery (1991) Vol. tt/No. 2 165

Figure 4. Injected air in the retroperitoneal space and mediasti- num, outlining the psoas muscles and kidneys.

Figure 3. Injected air in the right knee joint and between the muscles at the femur.

Saxton H. M. and Strickiand 8. (1972). Presacrai pneumography. In: Racti~~l Rocedures in Diagnostic Radiology. 2nd Ed. London: H. K. Lewis, 160.

Schoo M. J., Scott F. A. and Boswick J. A. (1980) High pressure injection injuries of the hand. J. Trauma 20, 229.

Wells D. T. (1976) Subcutaneous emphysema in a finger following

Figure 5. Injected air in the retroperitoneal space and mediasti-

num, outlining the psoas muscles and kidneys.

an injection injury. l-kznd 8, 59.

Paper accepted 6 July 1990.

Requests for reprints should be aa%esed to: Birgit Olesen, Blegdalspar- ken, 23st. th, DK 9000 Aalborg, Denmark.

Surgical emphysema: a delayed presentation of colonic trauma in multisystem injury

K. S. Balachandran and A. Allan Department of Surgery, Good Hope District General Hospital, Sutton Coldfield, UK

Surgical emphysema caused by gas leaking from the colon or rectum is rare. In 1853 Abeille described the perforation of a caecal abscess which caused surgical emphysema and subsequently some 17 similar cases have been recorded (Oetting et al., 1955; Banardi et al., 1976; Cameron-Strange

and Bemhoft, 1985; Bachir 1987). Such reports describe surgical emphysema either after surgery on the colorectum or less commonly after perforation of an underlying pathological lesion such as diverticulitis (Cameron-Strange and Bemhoft, 1985). This report describes a case of surgical

0020-1383/91/020165-02 0 1990 Butterworth-Heinemann Ltd