Abstract
Introduction: Necrotizing Fasciitis (NF) is a potentially lethal deep soft tissue infection. Correlation between prompt diagnosis and adequate surgical treatment and favorable outcome is well documented, however scarcity of specific cutaneous signs and the potential of evolution from otherwise simple infections may contribute to delay in diagnosis and treatment. Few clues may assist the physician to avoid overlooking this surgical emergency.
Patients and Methods: Sixty-eight patients were treated in our hospital for necrotizing fasciitis since 1990. In twenty-five of them the major involvement was peripheral, sparing the head, neck and torso. We reviewed these 25 cases for patterns of presentation and alarming signs for the first encountered physician, as well as for kinetics of treatment and outcome.
Results: Eight female and seventeen male patients aged 1–83 (average 53.6) years were treated. Only eight of them (32%) were free of comorbidities associated with reduced immunity. Majority of patients referred to the emergency department complaining of local pain/tenderness and erythema for few days accompanied by excruciating pain. Vital signs were often within normal limits, although leucocytosis on admission was common and gas was evident in the soft tissue by imaging. Surgical debridement was usually carried out on the day of diagnosis that was established immediately on admission in 10 cases (40%) but was delayed beyond 72 hours in seven patients (28%). CT scans showed severe edema and muscle liquefaction when taken. Thighs and gluteal region was the most common site of infection (56%) and cultures grew gram positive cocci (64%) and enteral flora (68%) in mono- and poly-microbial cultures. Only three cultures grew unaerobes, of which only one was clostridium. Accordingly, imaging studies showing gas in the soft tissue were uncommon. Eight patients (32%) have expired, and the average hospitalization period was over 38 days for the survivors.
Conclusions: NF is one of the surgical emergencies encountered by orthopedic surgeons. It is there, knocking at our door and will not go away… even a minor delay in diagnosis may be catastrophic to the patient, who often present with common signs and symptoms of mild to moderate skin infection. It should therefore be noted that pain inadequate for a minor infection was characteristic to most patients diagnosed with NF, and that CT findings may establish the diagnosis. Although considered pathognomonic, both crepitus and imaging finding of gas in the soft tissue are uncommon. Special attention to patients at risk and careful physical examination may lead to rapid diagnosis and treatment, and eventually lower the significant morbidity and mortality associated with this condition.
The abstracts were prepared by Ms Orah Naor. Correspondence should be addressed to Israel Orthopaedic Association at PO Box 7845, Haifa 31074, Israel.
