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Natural Gas Inflation Injury of the Upper Extremity: A Case Report
Natural Gas Inflation Injury of the Upper Extremity: A Case Report Thomas Sena, MD, Bruce W. Brewer, MD, East Meadow, NY High-pressure injection injury is well known to hand surgeons. We present a case of lowpressure inflation injury to the upper extremity. Our experience with this injury, its treatment, and the eventual outcome are discussed. (J Hand Surg 1999;24A:850 – 852. Copyright © 1999 by the American Society for Surgery of the Hand.) Key words: Hand, injury, injection, methane gas.
High-pressure injection injury of the hand has been well documented in the literature.1–3 The pathology and treatment of this injury is familiar to hand surgeons. This report describes a case of lowpressure inflation injury to the upper extremity with natural gas. We present our experience with this injury, its treatment, and its outcome.
Case Report A 19-year-old man presented to the emergency department with a swollen right upper extremity. He was working as a plumber’s assistant when he cut a natural gas pipe in a private home. He put his hand over the cut end of the pipe to stop the gas from leaking. A sharp edge caused a puncture wound to the palm of his hand, which served as a port of entry for the gas. After several minutes, the patient’s arm began to feel very heavy. Because of the heaviness, he presented to the emergency department concerned that his arm might be broken. On admission he had normal vital signs. Physical examination revealed swelling from the mid upper From the Division of Plastic Surgery, Department of Surgery, Nassau County Medical Center, East Meadow, NY. Received for publication September 19, 1995; accepted in revised form March 11, 1999. No benefits in any form have been received or will be received from a commercial party related directly or indirectly to the subject of this article. Reprint requests: Thomas Sena, MD, 507 Ocean Ave, New London, CT 06320. Copyright © 1999 by the American Society for Surgery of the Hand 0363-5023/99/24A04-0035$3.00/0
850 The Journal of Hand Surgery
arm to the fingertips. There was crepitance of the subcutaneous tissue in the entire area. There was an 8-mm puncture wound in the palm. Two-point discrimination was normal, as was capillary filling in the nail beds. The radial and ulnar pulses were present at the wrist. Range of motion of the extremity was limited due to swelling. The patient denied any pain or paresthesia of the hand. Complete blood cell and electrolyte counts were within normal limits. The patient had an unremarkable past medical history. X-ray films demonstrated the gas within the subcutaneous tissues of the forearm, hand, and fingers (Fig. 1). Debridement of the puncture wound was done in the emergency department under local anesthesia. A culture taken in the emergency department was negative. The local poison control center was unable to provide assistance. The patient was admitted to the hospital and treated with intravenous antibiotics, splinting of the involved extremity, and elevation. The patient was observed for response of the edema and neurologic compromise. The swelling reduced markedly within 48 hours. The patient was discharged on the third hospital day. He was seen as an outpatient on a weekly basis. Complete resolution of the swelling and full range of motion was noted by 2 weeks after injury.
Discussion This case represents a low-pressure natural gas inflation injury of the upper extremity. The natural gas piped into homes in the New York area is actu-
The Journal of Hand Surgery / Vol. 24A No. 4 July 1999 851
Figure 1. Posteroanterior (A) and lateral (B) x-ray films showing subcutaneous natural gas (arrows) in the right hand at the time of presentation.
ally a mixture of gases (Table 1) that is piped at an average pressure of 4.22 kg/cm2. Natural gas is lighter than air and thus rises. It is only combustible
Table 1. Properties of Natural Gas (Nearest Percent) Methane Carbon dioxide Nitrogen Ethane Butane, pentane, hexane, heptane
94% 1% 1% 3% 1%
From Consolidated Edison of New York information sheet.
when present in a 5% to 15% mixture with air. A gas–air mixture outside this range will not ignite (Consolidated Edison of New York information sheet). Natural gas also contains ethyl mercaptan, which adds an odor as a warning sign of leakage. Aside from its explosive properties, methane is also listed as a simple asphyxiant and has been noted to cause fatalities in waste pits.4 Natural gas is water soluble and is readily absorbed in the extracellular fluid of the body. Its main constituents, methane and ethane, are produced as byproducts in the gut of humans. Methane is present in flatus and diffuses across the colonic mucosa into
852 Sena and Brewer / Upper Extremity Gas Inflation Injury
the blood stream. Random breath analysis will detect methane in 30% to 50% of adults.5 Ethane is produced as a byproduct of lipid peroxidation and also can be measured in exhaled gases. The ethane exhalation rate can be used to measure free radical-induced tissue damage indirectly.6 Butane, pentane, hexane, heptane, and ethyl mercaptan are all irritants and affect the nervous system. They can cause headache, nausea, and vomiting or have a narcotic effect. High-pressure injection injuries involving grease or other toxins result in direct tissue injury due to an inflammatory response. These require aggressive treatment, including operative intervention, and may result in loss of the affected soft tissue. This lowpressure injury did not manifest any degree of damage to the surrounding tissue. Toxicity from the gases absorbed is minimized since these gases are produced as natural byproducts of metabolism and are excreted by the respiratory system. Thus, a more conservative approach can be undertaken. Simple elevation of the extremity was done to keep com-
partment pressure down while allowing the gases to absorb and dissipate and resulted in the successful treatment of this condition.
References 1. Fialkov JA, Freiberg A. High pressure injection injuries: an overview. J Emerg Med 1991;9:367–371. 2. Sirio CA, Smith JS Jr, Graham WP III. High-pressure injection injuries of the hand: a review. Am Surg 1989;55: 714 –718. 3. Harter BT Jr, Harter KC. High-pressure injection injuries. Hand Clin 1986;2:547–552. 4. Industrial Commission of Ohio, Columbus. Fatalities attributed to methane asphyxia in manure waste pits—Ohio, Michigan, 1989. MMWR Morb Mortal Wkly Rep 1989;38: 583–586. 5. Montes RG, Saavedra JM, Perman JA. Relationship between methane production and breath hydrogen excretion in lactose-malabsorbing individuals. Dig Dis Sci 1993;38:445– 448. 6. Habib MP, Dickerson F, Mooradian AD. Ethane production rate in vivo is reduced with dietary restriction. J Appl Physiol 1990;68:2588 –2590.
High-pressure injection injury of the hand has been well documented in the literature.1–3 The pathology and treatment of this injury is familiar to hand surgeons. This report describes a case of lowpressure inflation injury to the upper extremity with natural gas. We present our experience with this injury, its treatment, and its outcome.
Case Report A 19-year-old man presented to the emergency department with a swollen right upper extremity. He was working as a plumber’s assistant when he cut a natural gas pipe in a private home. He put his hand over the cut end of the pipe to stop the gas from leaking. A sharp edge caused a puncture wound to the palm of his hand, which served as a port of entry for the gas. After several minutes, the patient’s arm began to feel very heavy. Because of the heaviness, he presented to the emergency department concerned that his arm might be broken. On admission he had normal vital signs. Physical examination revealed swelling from the mid upper From the Division of Plastic Surgery, Department of Surgery, Nassau County Medical Center, East Meadow, NY. Received for publication September 19, 1995; accepted in revised form March 11, 1999. No benefits in any form have been received or will be received from a commercial party related directly or indirectly to the subject of this article. Reprint requests: Thomas Sena, MD, 507 Ocean Ave, New London, CT 06320. Copyright © 1999 by the American Society for Surgery of the Hand 0363-5023/99/24A04-0035$3.00/0
850 The Journal of Hand Surgery
arm to the fingertips. There was crepitance of the subcutaneous tissue in the entire area. There was an 8-mm puncture wound in the palm. Two-point discrimination was normal, as was capillary filling in the nail beds. The radial and ulnar pulses were present at the wrist. Range of motion of the extremity was limited due to swelling. The patient denied any pain or paresthesia of the hand. Complete blood cell and electrolyte counts were within normal limits. The patient had an unremarkable past medical history. X-ray films demonstrated the gas within the subcutaneous tissues of the forearm, hand, and fingers (Fig. 1). Debridement of the puncture wound was done in the emergency department under local anesthesia. A culture taken in the emergency department was negative. The local poison control center was unable to provide assistance. The patient was admitted to the hospital and treated with intravenous antibiotics, splinting of the involved extremity, and elevation. The patient was observed for response of the edema and neurologic compromise. The swelling reduced markedly within 48 hours. The patient was discharged on the third hospital day. He was seen as an outpatient on a weekly basis. Complete resolution of the swelling and full range of motion was noted by 2 weeks after injury.
Discussion This case represents a low-pressure natural gas inflation injury of the upper extremity. The natural gas piped into homes in the New York area is actu-
The Journal of Hand Surgery / Vol. 24A No. 4 July 1999 851
Figure 1. Posteroanterior (A) and lateral (B) x-ray films showing subcutaneous natural gas (arrows) in the right hand at the time of presentation.
ally a mixture of gases (Table 1) that is piped at an average pressure of 4.22 kg/cm2. Natural gas is lighter than air and thus rises. It is only combustible
Table 1. Properties of Natural Gas (Nearest Percent) Methane Carbon dioxide Nitrogen Ethane Butane, pentane, hexane, heptane
94% 1% 1% 3% 1%
From Consolidated Edison of New York information sheet.
when present in a 5% to 15% mixture with air. A gas–air mixture outside this range will not ignite (Consolidated Edison of New York information sheet). Natural gas also contains ethyl mercaptan, which adds an odor as a warning sign of leakage. Aside from its explosive properties, methane is also listed as a simple asphyxiant and has been noted to cause fatalities in waste pits.4 Natural gas is water soluble and is readily absorbed in the extracellular fluid of the body. Its main constituents, methane and ethane, are produced as byproducts in the gut of humans. Methane is present in flatus and diffuses across the colonic mucosa into
852 Sena and Brewer / Upper Extremity Gas Inflation Injury
the blood stream. Random breath analysis will detect methane in 30% to 50% of adults.5 Ethane is produced as a byproduct of lipid peroxidation and also can be measured in exhaled gases. The ethane exhalation rate can be used to measure free radical-induced tissue damage indirectly.6 Butane, pentane, hexane, heptane, and ethyl mercaptan are all irritants and affect the nervous system. They can cause headache, nausea, and vomiting or have a narcotic effect. High-pressure injection injuries involving grease or other toxins result in direct tissue injury due to an inflammatory response. These require aggressive treatment, including operative intervention, and may result in loss of the affected soft tissue. This lowpressure injury did not manifest any degree of damage to the surrounding tissue. Toxicity from the gases absorbed is minimized since these gases are produced as natural byproducts of metabolism and are excreted by the respiratory system. Thus, a more conservative approach can be undertaken. Simple elevation of the extremity was done to keep com-
partment pressure down while allowing the gases to absorb and dissipate and resulted in the successful treatment of this condition.
References 1. Fialkov JA, Freiberg A. High pressure injection injuries: an overview. J Emerg Med 1991;9:367–371. 2. Sirio CA, Smith JS Jr, Graham WP III. High-pressure injection injuries of the hand: a review. Am Surg 1989;55: 714 –718. 3. Harter BT Jr, Harter KC. High-pressure injection injuries. Hand Clin 1986;2:547–552. 4. Industrial Commission of Ohio, Columbus. Fatalities attributed to methane asphyxia in manure waste pits—Ohio, Michigan, 1989. MMWR Morb Mortal Wkly Rep 1989;38: 583–586. 5. Montes RG, Saavedra JM, Perman JA. Relationship between methane production and breath hydrogen excretion in lactose-malabsorbing individuals. Dig Dis Sci 1993;38:445– 448. 6. Habib MP, Dickerson F, Mooradian AD. Ethane production rate in vivo is reduced with dietary restriction. J Appl Physiol 1990;68:2588 –2590.