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Ano-rectal injury causing extraperitoneal and subcutaneous emphysema
Injury: the British Journal of Accident Surgery (1987) Vol. 18/No. 6
426
Ano-rectal injury causing extraperitoneal subcutaneous emphysema
and
P. R. S. Thomas Whipps Cross Hospital,
Leytonstone,
London
Summary Extraperitoneal emphysema is a rare clinical finding, usually reported in association with iatrogenic injuries to the rectum. Minor degrees of ‘extraperitoneal emphysema’ may be seen in other perforations but insufflation of air seems to be the major contributory factor. This report describes an unusual case that developed after a straddle-injury.
CASE REPORT An &year-old boy presented with increasing lower abdominal pain, having sustained a blunt straddle injury in falling from a wall 4 hours earlier. He was pyrexial, had a tachycardia, and examination revealed moderate distension of the lower abdomen. There was marked subcutaneous crepitus extending from the groins up to the costal margin but little tenderness and no guarding. Bowel sounds were normal. He passed urine without difficulty and urinalysis was normal. Radiography (Fig. 1) showed subcutaneous emphysema of the groins and lower abdominal wall with extrarectal gas extending up the retroperitoneal space clearly outlining the left psoas muscle and kidney. There was no free intraperitoneal air and the chest radiograph showed no extension into the mediastinum or neck. He was given antibiotics and tetanus prophylaxis. Examination under anaesthesia showed perineal contusions with a l-cm wide tear at the posterior anal margin extending up the anal canal to the dentate line. The sphincter muscles were exposed but appeared intact and the rectum was otherwise normal. Sigmoidoscopy revealed no other mucosal injury, foreign body or evidence of sexual abuse, which was a major concern in this setting. At laparotomy there was no free intraperitoneal air but marked surgical emphysema which extended from the pararectal tissues up into the mesosigmoid and had stripped the peritoneum off the posterior abdominal wall. There was no blood or faecal soiling evident and no perforation was identified. Other sites of possible injury were inspected and found to be normal. A loop colostomy was fashioned in the left iliac fossa and the presacral space was’ drained. Postoperatively he made an uneventful recovery, and the subcutaneous emphysema resolved by the time of his discharge 8 days later.
DISCUSSION Extraperitoneal emphysema with subcutaneous emphysema is an unusual complication of extraperitoneal rupture of the rectum, usually associated with iatrogenic procedures. The earliest case report (Jones, 1949) described a patient who developed subcutaneous emphysema of the neck following proctoscopy, and suggested rupture of an emphysematous bulla as the likely cause. A subsequent and similar report (Borgstom, 1953) observed that perforation of the rectum below the peritoneal reflection allows air to track up the retroperitoneal space and if it extends up to the diaphragm may mimic a free intraperitoneal perforation. They may be differentiated by the tendency of
free intraperitoneal air to be mobile and localize to the dome of the diaphragm whereas extraperitoneal air is usually more laterally placed and crescent shaped (Walker et al., 1982). If there is further dissection this space communicates superiorly with the posterior mediastinum producing subcutaneous emphysema of the neck, and inferiorly with the groins producing emphysema of the lower abdominal wall. The relative severity of extraperitoneal emphysema when complicating barium enemas (Walker et al., 1982) colonoscopy (Schmidt et al., 1986) and mechanical ventilation (Hillman, 1983), suggests that insufflation of air is the major causative factor.
Fig. 1. Radiograph showing subcutaneous emphysema of the groins and lower abdominal wall with extrarectal gas extending up the retroperitoneal space.
Case reports
427
The management of extraperitoneal perforations of the rectum has recently been reviewed (Grasberger and Hirch, 1983). After minor impalement injuries, a local operation to remove foreign material and improve drainage will often suffice and as iatrogenic injuries usually occur in a ‘prepared’ bowel, these may be successfully managed without surgery if carefully monitored and covered with appropriate antibiotics (Walker et al., 1982, Schmidt et al., 1986). Finally, as sexual abuse accounts for over 80 per cent of anorectal trauma in children (Black et al., 1982) suspicious be investigated by the paediatric services.
cases should
Black C. T., Porkorny W. J., McGill C. W. et al. (1982) Anorectal trauma in children. J. Pediutr. Surg. 17(5), 501. Grasberger R. C. and Hirch E. F. (1983) Rectal trauma. Am. J. Surg. 145, 795.
Hillman K. M. (1983) Pneumoretroperitoneum.
Anaesthesiu
38, 136.
Jones J. D. T. (1949) Perforation 1, 933.
of the rectum. Br. Med. J.
Schmidt G., Borsch G. and Wegener M. (1986) Subcutaneous emphysema and pneumothorax complicating diagnostic colonoscopy. Dis. Colon Rectum 29(2). 136. Walker H. C., Nivatvongs S., Ansel H. et al. (1982) Massive extraperitoneal air in a 71 year old woman. JAMA 248(11), 1375.
REFERENCES
Borgstrom S. (1953) Subcutaneous emphysema following recActu Chir. Stand. 104, 465.
tal perforation.
Requests for reprints should be addressed to: P. R. S. Thomas
Paper accepted 14 April 1987. FKCS, St
James’ Hospital, SarsfieldRoad, London ~~12 8HW.
False aneurysm of the axillary artery as a complication the modified Bristow procedure M. J. Clancy Orthopaedic
Department,
Royal United Hospital,
Bath
INTRODUCTION modified Bristow procedure is becoming increasingly popular as the operative treatment of recurrent anterior dislocation of the shoulder. It consists of transplantation of the coracoid process with the attached tendons of the short head of biceps and coracobrachialis to the anterior rim of the glenoid. The subscapularis is split and the coracoid is secured with a bone screw. The rising popularity of this operation is attributable to the fact that there is preservation of a greater range of movement with a redislocation rate similar to other procedures, and it is technically straightforward. This report draws attention to a serious neurovascular complication of the procedure.
THE
CASE REPORT A 32-year-old male industrial cleaner who had sustained five dislocations of the left shoulder following a fall in 1977, underwent a modified Bristow procedure in October, 1978. He complained of pain in his left shoulder in 1980, when a loosened screw was noted; no treatment was prescribed. He returned in February 1985 with sudden onset of pain in his left shoulder whilst. removing an electric plug from a wall socket. This was followed by the rapid development of a swelling in front of his left shoulder and pain down the inner side of his arm, with tingling in his left hand. Examination revealed a large, tense swelling anterior to his shoulder joint with reduced movement of the shoulder. The motor function of his arm was considered normal. One week later he was admitted with rapid onset of progressive weakness and numbness of the left arm.
Fig. 1. Left subclavian arteriogram.
of
426
Ano-rectal injury causing extraperitoneal subcutaneous emphysema
and
P. R. S. Thomas Whipps Cross Hospital,
Leytonstone,
London
Summary Extraperitoneal emphysema is a rare clinical finding, usually reported in association with iatrogenic injuries to the rectum. Minor degrees of ‘extraperitoneal emphysema’ may be seen in other perforations but insufflation of air seems to be the major contributory factor. This report describes an unusual case that developed after a straddle-injury.
CASE REPORT An &year-old boy presented with increasing lower abdominal pain, having sustained a blunt straddle injury in falling from a wall 4 hours earlier. He was pyrexial, had a tachycardia, and examination revealed moderate distension of the lower abdomen. There was marked subcutaneous crepitus extending from the groins up to the costal margin but little tenderness and no guarding. Bowel sounds were normal. He passed urine without difficulty and urinalysis was normal. Radiography (Fig. 1) showed subcutaneous emphysema of the groins and lower abdominal wall with extrarectal gas extending up the retroperitoneal space clearly outlining the left psoas muscle and kidney. There was no free intraperitoneal air and the chest radiograph showed no extension into the mediastinum or neck. He was given antibiotics and tetanus prophylaxis. Examination under anaesthesia showed perineal contusions with a l-cm wide tear at the posterior anal margin extending up the anal canal to the dentate line. The sphincter muscles were exposed but appeared intact and the rectum was otherwise normal. Sigmoidoscopy revealed no other mucosal injury, foreign body or evidence of sexual abuse, which was a major concern in this setting. At laparotomy there was no free intraperitoneal air but marked surgical emphysema which extended from the pararectal tissues up into the mesosigmoid and had stripped the peritoneum off the posterior abdominal wall. There was no blood or faecal soiling evident and no perforation was identified. Other sites of possible injury were inspected and found to be normal. A loop colostomy was fashioned in the left iliac fossa and the presacral space was’ drained. Postoperatively he made an uneventful recovery, and the subcutaneous emphysema resolved by the time of his discharge 8 days later.
DISCUSSION Extraperitoneal emphysema with subcutaneous emphysema is an unusual complication of extraperitoneal rupture of the rectum, usually associated with iatrogenic procedures. The earliest case report (Jones, 1949) described a patient who developed subcutaneous emphysema of the neck following proctoscopy, and suggested rupture of an emphysematous bulla as the likely cause. A subsequent and similar report (Borgstom, 1953) observed that perforation of the rectum below the peritoneal reflection allows air to track up the retroperitoneal space and if it extends up to the diaphragm may mimic a free intraperitoneal perforation. They may be differentiated by the tendency of
free intraperitoneal air to be mobile and localize to the dome of the diaphragm whereas extraperitoneal air is usually more laterally placed and crescent shaped (Walker et al., 1982). If there is further dissection this space communicates superiorly with the posterior mediastinum producing subcutaneous emphysema of the neck, and inferiorly with the groins producing emphysema of the lower abdominal wall. The relative severity of extraperitoneal emphysema when complicating barium enemas (Walker et al., 1982) colonoscopy (Schmidt et al., 1986) and mechanical ventilation (Hillman, 1983), suggests that insufflation of air is the major causative factor.
Fig. 1. Radiograph showing subcutaneous emphysema of the groins and lower abdominal wall with extrarectal gas extending up the retroperitoneal space.
Case reports
427
The management of extraperitoneal perforations of the rectum has recently been reviewed (Grasberger and Hirch, 1983). After minor impalement injuries, a local operation to remove foreign material and improve drainage will often suffice and as iatrogenic injuries usually occur in a ‘prepared’ bowel, these may be successfully managed without surgery if carefully monitored and covered with appropriate antibiotics (Walker et al., 1982, Schmidt et al., 1986). Finally, as sexual abuse accounts for over 80 per cent of anorectal trauma in children (Black et al., 1982) suspicious be investigated by the paediatric services.
cases should
Black C. T., Porkorny W. J., McGill C. W. et al. (1982) Anorectal trauma in children. J. Pediutr. Surg. 17(5), 501. Grasberger R. C. and Hirch E. F. (1983) Rectal trauma. Am. J. Surg. 145, 795.
Hillman K. M. (1983) Pneumoretroperitoneum.
Anaesthesiu
38, 136.
Jones J. D. T. (1949) Perforation 1, 933.
of the rectum. Br. Med. J.
Schmidt G., Borsch G. and Wegener M. (1986) Subcutaneous emphysema and pneumothorax complicating diagnostic colonoscopy. Dis. Colon Rectum 29(2). 136. Walker H. C., Nivatvongs S., Ansel H. et al. (1982) Massive extraperitoneal air in a 71 year old woman. JAMA 248(11), 1375.
REFERENCES
Borgstrom S. (1953) Subcutaneous emphysema following recActu Chir. Stand. 104, 465.
tal perforation.
Requests for reprints should be addressed to: P. R. S. Thomas
Paper accepted 14 April 1987. FKCS, St
James’ Hospital, SarsfieldRoad, London ~~12 8HW.
False aneurysm of the axillary artery as a complication the modified Bristow procedure M. J. Clancy Orthopaedic
Department,
Royal United Hospital,
Bath
INTRODUCTION modified Bristow procedure is becoming increasingly popular as the operative treatment of recurrent anterior dislocation of the shoulder. It consists of transplantation of the coracoid process with the attached tendons of the short head of biceps and coracobrachialis to the anterior rim of the glenoid. The subscapularis is split and the coracoid is secured with a bone screw. The rising popularity of this operation is attributable to the fact that there is preservation of a greater range of movement with a redislocation rate similar to other procedures, and it is technically straightforward. This report draws attention to a serious neurovascular complication of the procedure.
THE
CASE REPORT A 32-year-old male industrial cleaner who had sustained five dislocations of the left shoulder following a fall in 1977, underwent a modified Bristow procedure in October, 1978. He complained of pain in his left shoulder in 1980, when a loosened screw was noted; no treatment was prescribed. He returned in February 1985 with sudden onset of pain in his left shoulder whilst. removing an electric plug from a wall socket. This was followed by the rapid development of a swelling in front of his left shoulder and pain down the inner side of his arm, with tingling in his left hand. Examination revealed a large, tense swelling anterior to his shoulder joint with reduced movement of the shoulder. The motor function of his arm was considered normal. One week later he was admitted with rapid onset of progressive weakness and numbness of the left arm.
Fig. 1. Left subclavian arteriogram.
of