Case Presentation A 70yo M presented to the Emergency Department with non-painful swelling of the face, neck, chest, and upper limbs, 11 days after a NOF + ORIF under spinal anaesthesia. Managment Examination revealed marked subcutaneous emphysema over the chest, face, and arms, with multiple non-tender anterior abdominal wall hernias. He became febrile with elevated inflammatory markers while admitted, CT demonstrated extensive soft tissue emphysema involving the neck, chest, and abdominal walls, mediastinal emphysema, and a segmental pulmonary embolism. Within 24 hours, abdominal pain developed with feculent discharge from a ventral hernia, erythema, and cellulitis. Multidisciplinary assessment suggested an enterocutaneous fistula from a bowel-containing hernia as the source. The patient underwent urgent segmental colectomy, excision of the fistula, extensive abdominal wall debridement, and negative-pressure wound therapy. Outcome Postoperative complications included VRE infection, stoma hemorrhage, and abdominal collections requiring relook surgery. Following intervention, his cellulitis and inflammatory markers improved, and he recovered with completion of intravenous antibiotics. Conclusion Subcutaneous emphysema secondary to abdominal perforation is rare, with high morbidity and mortality [1]. Early recognition and timely surgical management are critical to limit progression and improve outcomes. This case further proves subcutaneous emphysema in abdominal perforation is likely involved in tracking of free air along fascial planes, more so in relation to increased abdominal pressure or pre existing abdominal defects such as hernias, causing further spread into deeper, softer, tissue planes [2]. References [1] G. Kuhn, J. Lekeufack and M. Chilcott, Subcutaneous Emphysema Caused by an Extraperitoneal Diverticulum Perforation: Description of Two Rare Cases and Review of the Literature, Wiley, 2018. [2] P. Sutton, M. Jenner-O'Brien and D. Monk, Subcutaneous emphysema of the abdominal wall, BMJ, 2013.