Necrotizing fasciitis

Necrotizing fasciitis is a rare soft tissue infection with a high rate of mortality. Decreased capacity of the immune response is the overall disposing factor. Necrotizing fasciitis can develop very rapidly, and a rapid diagnosis and aggressive surgery provides the best prognosis.     

Necrotizing fasciitis

The author's experience of fourteen patients with necrotizing fasciitis is reviewed. The pathognomonic feature of this condition is an extensive necrosis of subcutaneous tissue caused by a vicious cycle of infection, local ischaemia and reduced host defence mechanisms. The diagnosis can only be confirmed by immediate exploratory incision. The reported mortality of 30-40% reflects the inadaquacy of conservative surgery in the treatment of this serious condition. Mortality can be reduced by early recognition followed by radical excision of the necrotic fascia and overlying skin. The preservation and subsequent use of the excised skin has the advantage of economy in the use of donor areas and reduction in morbidity. Hyperbaric oxygen therapy does not halt the spread of the necrotizing process and is not a substitute for radical surgery.     

Necrotizing fasciitis of the face

Necrotizing fasciitis (NF) is a rapidly progressive soft tissue infection with high morbidity and mortality rates. Its occurrence in the head and neck region is uncommon, the majority of reported cases being limited to involvement of the neck, usually from infections of dental or pharyngeal origin. Involvement of the face from NF is rare; only 35 such cases have been reported in the literature since 1960. It is not only associated with a high mortality but can also result in severe disfigurement of the face, posing challenging reconstructive problems. Successful management of facial NF requires early diagnosis, prompt institution of broad spectrum antibiotics, aggressive surgical debridement to control the infection, and reconstruction of the resultant soft tissue defects. This report describes four additional cases of facial necrotizing fasciitis. One of the four patients died as a result of sepsis and multi-organ system failure. Two of the three surviving patients had significant facial disfigurement. A comprehensive review of the facial NF cases reported in the literature is also provided. Based on our experience with facial NF and the results of all previous case reports, the clinical manifestations, pathogenesis, and management of this disease are discussed.     

Necrotizing fasciitis after Plastibell circumcision

Necrotizing fasciitis is a potentially life-threatening infection of subcutaneous tissues and Scarpa's fascia that rarely affects neonates. We report the occurrence of this devastating infection in two neonates after routine Plastibell circumcision. These case reports highlight the presentation and management of this complication after a relatively routine and frequently performed operation. This report also emphasizes the differences between cellulitis and necrotizing fasciitis and suggests strategies for management.     

Necrotizing fasciitis after tumescent liposuction

We report a case of necrotizing fasciitis after tumescent liposuction, a new and increasingly popular plastic surgery procedure. After radical surgical debridement and staged full-thickness skin grafting, the patient ultimately recovered. The significance and recognition of this serious complication is emphasized.     

Necrotizing fasciitis: apropos of a case

Necrotizing fasciitis is an infection which involves soft tissues up to the fascia, with wide areas of necrosis, and is mainly caused by group A beta-hemolytic Streptococcus. The Authors report a case recently observed and after an accurate review of the Literature, taking into account the most recent pathogenetic knowledges, confirm the necessity of an early diagnosis based on clinical criteria but above all on histological biopsy. The treatment is mainly surgical, and allows, together with the medical treatment, to subdue the rapid progression of the infection which notwithstanding maintains an high mortality rate.     

Necrotizing fasciitis of the head and neck. Report of 4 cases of cervical necrotizing fasciitis]

Necrotizing fasciitis is a severe polybacteria infection characterised by necrosis of the fascial and adjacent soft tissues with rapid expansion of the infection along fascial planes. It may originate potentially fatal complications and often is accompanied by systemic toxicity. It is not a frequent entity in the head and neck, but early diagnosis is very important because early treatment based on intravenous antibiotherapy and aggressive surgical debridement can prevent complications that often cause the death of the patient. Pour reports of necrotizing fasciitis are presented, one of them with fatal outcome, which leads us to emphasize the importance of an early diagnosis.     

Necrotizing fasciitis: case study of a nursing dilemma

Necrotizing fasciitis usually manifests as a low grade cellulitis that quickly deteriorates to a limb and life threatening soft tissue infection. Immediate surgical debridement is essential, after which wound management becomes the nurse's primary concern. Case #1 reports on a 72 year old female who, upon presenting to the ER with a "sore bottom," subsequently had these diagnoses: (1) anal-rectal abscess, (2) Fournier's gangrene, (3) ulcerative enterocolitis, (4) chronic blood loss/anemia, and (5) protein caloric malnutrition. After debridement, her anal-rectal wound extended from labia to left buttocks. Care was multidisciplinary and included applying a water based aloe gel and saline soaked gauze twice a day. After 45 days, the wound exhibited a pink base with granulation tissue and contraction of the wound edges. Case #2 reports on a 48 year old male with seroma of the left leg secondary to a crush injury. Within three days he developed deep vein thrombosis in that leg as well as two large seroma cavities on either side of the thigh. Care included packing with the aloe gel and saline soaked sponges. Two weeks after admission, the anterior wound was covered with a split thickness skin graft while partial closure of the lateral cavity was attempted unsuccessfully with retention sutures. After five weeks, healing was complete for the anterior wound and 95 percent complete for the posterior wound.     

Prosthesis of the upper extremity

In functional impairment of a joint due to pain and (or) limited mobility in which conservative measures are inadequate, an operation may be considered. The principal possibilities are arthrodesis and implantation of an artificial joint. Reasons to opt for a prosthesis are involvement of adjacent articulations (in rheumatoid arthritis) and preservation of mobility which, together with stability, is necessary for good articular function. The principal indications for implantation of an artificial joint in the upper extremity are rheumatoid arthritis and (to a lesser degree) osteoarthritis and posttraumatic impairments. The functional results of prostheses in the shoulder, elbow and wrist are good, but the proportion of complications is relatively large (compared with that in hip and knee prostheses) and follow-up so far has only been short.     

Necrotizing fasciitis following laparoscopic surgery. Case report and review of the literature

Necrotizing fasciitis is a rare and potentially fatal infection characterized by rapid and progressive involvement of the fascia and subcutaneous tissues. Early diagnosis, aggressive initial debridement followed by planned redebridements in conjunction with nutritional support and antibiotics remain the mainstay of therapy. We present a case of necrotizing fasciitis of the abdominal wall following a laparoscopically assisted vaginal hysterectomy. Literature is reviewed and discussed with reference to this catastrophic infection in the age of laparoscopic surgery.     

Neurologic evaluation of the upper extremity

Symptoms and disease processes can overlap, and neurologic symptoms of the hand or arm are not necessarily due to local pathology. To combat these difficulties, the authors present a basic review of neuroanatomy, the neurologic examination, the principles of electromyography, and the process of formulation.     

Necrotizing fasciitis and myonecrosis in early childhood: a report of three patients

Necrotizing fasciitis (NF) is a rare and life-threatening disease. It usually presents as a postoperative complication, but rarely appears following trauma or without apparent cause. Over a period of 2 years we have treated three infants with NF, aged 15, 5, and 30 months, respectively. Two patients developed this complication following minor trauma while the third was post-elective bilateral inguinal hernia repair. The micro-organisms isolated were Staphylococcus aureus with Enterococcus durans in one patient, beta-hemolytic streptococcus in a second, and Staph. aureus in the third. The cornerstone of therapy is prompt, early, aggressive surgical debridement of the massive necrotic tissue and repeated debridement if necessary, with appropriate parenteral antibiotic therapy and hyperalimentation. All three patients survived. Early recognition of this life-threatening situation is mandatory in achieving survival.     

Dislocations of the upper extremity in children

Traumatic dislocations and subluxations of the upper extremity in children have been surveyed. The elbow joint is most commonly dislocated and is dislocated more frequently in children than in adults. Severe neurovascular injury may be associated with dislocation of this joint. The most common subluxation is that of the radial head, secondary to a "pulled elbow." Otherwise dislocations and subluxations of the upper extremity are uncommon in children, apparently because of the relative weakness of the epiphyseal plate. Most of these injuries are the result of predictable indirect forces. Principles of reduction and immobilization are based on the unique anatomic structure of the joint involved and the known anatomic disruption resulting from the trauma.     

Anatomy of the upper extremity muscle compartments

Schizophrenia, a devastating disease characterized by a combination of various types of disturbed behaviors, thoughts, and feelings, may likewise be heterogeneous in etiology. Recent advances in neuroscience and psychopharmacology have suggested a wide array of competing mechanisms that may be involved in schizophrenia, including but not limited to deficits in one or more neurotransmitters and second messenger systems (e.g., dopamine, serotonin, gamma-aminobutyric acid, glutamate, and noradrenaline), neurodevelopmental defects in brain circuitry, and viral infection. Psychiatric genetic studies indicate that schizophrenia is a disorder with multifactorial inheritance. Since cerebral metabolic activity reflects regional brain work for all neurotransmitter systems, imaging metabolism directly with fluorodeoxyglucose and indirectly with blood flow and hemoglobin oxygen saturation can provide information about the functional neuroanatomy of a deficit in individual patients and allow patients to be grouped into more homogeneous subgroups for intensive study. This review summarizes metabolic imaging studies in schizophrenia over the past decade.     

Volkmann's ischemic contracture of the upper extremity

Upper extremity deformity of ischemic contracture usually includes elbow flexion, forearm pronation, wrist flexion, thumb flexion and adduction, digital metacarpophalangeal joint extension, and interphalangeal joint flexion. Treatment of mild contractures consists of either nonoperative management with a comprehensive rehabilitation program (to increase range of motion and strenght) or operative management consisting of infarct excision or tendon lengthening. Treatment of moderate-to-severe contractures consists of release of secondary nerve compression, treatment of contractures (with tendon lengthening or recession), tendon or free-tissue transfers to restore lost function, and/or salvage procedures for the severely contracted or neglected extremity.     

Exertional compartment syndrome of the upper extremity

Exertional compartment syndrome is characterized by intracompartmental pressures that rise transiently following repetitive motion or exercise, thereby producing temporary, reversible ischemia, pain, weakness, and, occasionally, neurologic deficits. The exact cause or pathogenesis remains unclear; a disturbance of microvascular flow caused by elevated intramuscular pressure leads to tissue ischemia, depletion of high-energy phosphate stores, and cellular acidosis. Anatomic contributing factors may include a limited compartment size, increased intracompartmental volume, constricted fascia, loss of compartment elasticity, poor venous return, or increased muscle bulk. The diagnosis is suspected based on history and confirmed with physical examination and intramuscular pressure evaluation before and after exercise (stress test). Differential diagnosis includes claudication or other vascular abnormalities, myositis, tendinitis, periostitis, chronic strains or sprains, stress fracture, other compression or systemic neuropathies, and cardiac abnormalities with angina or referred extremity pain. Initial treatment includes activity modification; refractory symptoms can be managed with elective fasciotomy.     

Necrotizing fasciitis following postpartum tubal ligation. A case report and review of the literature

Necrotizing fasciitis is a rare, but devastating subcutaneous bacterial infection which occurs following breaks in skin integrity, either natural, post traumatic or post surgical. Although it has been described following many surgical procedures, necrotizing fasciitis has not been previously described following postpartum tubal ligation. Necrotizing fasciitis was diagnosed four days after an uncomplicated postpartum tubal ligation via an infraumbilical incision. Rapid surgical debridement with broad spectrum antibiotic coverage provided successful therapy. Postpartum tubal ligation is one of the most common surgical procedures in obstetrics and gynecology, thus reports of complications resulting from this procedure are quite relevant to clinical practice. We present here the first reported case of necrotizing fasciitis following postpartum tubal ligation through an infraumbilical incision.     

Cubital tunnel syndrome and the painful upper extremity

Cubital tunnel syndrome is the second-most-common compressive neuropathy. With the increasing prevalence of entrapment neuropathies, the presentation of ulnar nerve compression with a painful upper extremity appears to be more common. Although our knowledge and understanding of this disease are increasing, the principles of management remain constant. We are obliged to reach a timely and appropriate diagnosis to minimize the extent of neurologic injury and institute an appropriate treatment regimen to preserve and restore normal neural function. Although there are many ways to reach these goals, the avoidance of complications is paramount to achieve a reliable and pain-free outcome. Preventing injury to the medial antebrachial cutaneous nerve, complete release of all sites of compression, and avoidance of creating new compressive sites are the keys to this end.     

Soft tissue coverage for the upper extremity

Soft tissue coverage of the upper extremity continues to be a challenging and evolving field. The expeditious and reliable methods of soft tissue coverage currently in use are discussed with reference to their shortcomings and advantages. For soft tissue coverage of fingertip injuries, open treatment or local flaps from the hand remain the mainstay of treatment. For dorsal and volar hand defects, distal axial flaps, such as the groin flap or microvascular tissue transfer, are utilized most commonly. For large defects proximal to the wrist, trunk axial pattern flaps, microvascular transfer, or the radial forearm flap have the greatest utility. Finally, technical points necessary for the success of some of the flaps are discussed.     

Dynamic skeletal fixation in the upper extremity

Recent advances in the understanding of the biomechanics of the elbow and improvement in material designs have revolutionized the ability to treat difficult problems of the proximal interphalangeal and elbow joints. Dynamic skeletal fixation addresses the desire to allow an injured joint to heal, move, and remain stable simultaneously. In the past, such goals were achieved sequentially or in series. It is now possible to perform such tasks in parallel.