Necrotising fasciitis of the upper limb: an Auckland experience
View Article PDF
Necrotising fasciitis (NF) is a severe and rapidly fulminating septic process, primarily involving subcutaneous and fascial tissues. It has the potential to spread precipitously to involve an entire limb resulting in significant soft tissue defects and in some cases amputation and death. The upper extremity is less commonly affected (6–27%) compared with other anatomical sites and the diagnosis is often challenging.1,2 Early surgical debridement is the single most important factor in determining outcome3–7 and delay in treatment adversely impacts mortality.8
Due to the rarity of upper extremity NF, its description in the literature has been limited to case reports, small studies or large studies of mixed anatomical sites which included the upper limb. Mortality rates for the upper extremity have been reported as high as 36%.9 Factors predicting mortality for NF of the upper extremity include altered level of consciousness and respiratory distress on presentation2 as well as more proximal involvement of a limb.9 NF has been shown to be twice as prevalent in the South Auckland population compared with the rest of the developed world.10 Investigation into these factors of the upper extremity is yet to be done on an Australasian population.
This study aimed to comment on the incidence and outcomes of NF of the upper limb in Auckland, New Zealand. It looked at the characteristics of patients with upper limb NF to assess whether any characteristics could be correlated with outcomes. The hypothesis was that an older age, history of immunosuppression and delay until first debridement would result in higher rates of morbidity and mortality.
Methods
A retrospective review of all patients treated with necrotising fasciitis of the upper limb at the Auckland Regional Centre for Plastic, Reconstructive and Hand Surgery between 1 January 2006 and 1 December 2015 was performed. Diagnosis was made intraoperatively by the surgical team with the presence of necrotic fascia removed easily with blunt dissection in conjunction with purulence resembling a ‘dishwater’ appearance (Figure 2, 3). Patient demographics, clinical features, laboratory and radiological investigations, surgical parameters, reconstruction methods and immediate and long-term outcomes were investigated. QuickDASH (Disabilities of Arm, Shoulder and Hand) and Patient Evaluation Measure (PEM) questionnaires (Figure 1) were used to evaluate subjective outcomes. Tests of association was carried out between each of the clinical characteristics and mortality, using Fisher exact test for the categorical variables and non-parametric test for the continuous variables.
Figure 1: Patient Evaluation Measure (PEM) questionnaire sections 2 and 3 utilised for this study.
Figure 2: Prior to first debridement, 43 hours after presentation. ‘Dishwater appearance noted with gentle blunt debridement’.
Figure 3: Dorsal forearm fascia during first debridement.
Results
Fifteen patients were identified. Mean follow-up time was 24 (standard deviation [SD]21) months. Mean age at admission was 54 (SD:21) years (Table 1). Forty-seven percent were NZ European, 40% Polynesian and 13% Māori. Positive smoking history was recorded in 40% of patients. The most common comorbidity seen was type 2 diabetes (40%). Only one case had a history of intravenous drug usage (IVDU). The most common initial site of symptomatology was the hand (60%) followed by the elbow (20%), forearm (13%) and chest wall (7%). Ninety-three percent of cases had positive tissue cultures of which the most frequently isolated organism was Streptococcus pyogenes (73%). Polymicrobial cultures were seen in 57%. The majority of patients initially received an antibiotic regime of intravenous Penicillin, Clindamycin and Gentamycin until a specific organism(s) was isolated. Mean time to the operating room from admission was 47 (SD: 84) hours. Patients underwent a mean of 3.4 debridements and 12 cases underwent reconstruction (11 split skin graft, one anterolateral thigh free flap). Reconstruction did not occur in three cases; two due to mortality and one healed satisfactorily by secondary intention. Mean length of hospital admission was 17.6 (SD:12.4) days.
Table 1: Univariate analysis.
Three patients (20%) died in our study, all due to disease specific causes. Two deceased cases were complicated by multi-organ dysfunction secondary to septicaemia. One deceased case was complicated by hospital-acquired pneumonia and septicaemia-induced arrhythmia with subsequent cardiac dysfunction. Univariate analysis (Table 1) demonstrated older age (p=0.017), hypertensive disease (p=0.044) and the need for amputation (p=0.029) were significantly associated with mortality. Requirement for amputation in the two cases indicated the difficulty in controlling the infection; correlating with more severe disease course as opposed to a lack of reconstructive options. Ethnicity, diabetes, smoking history, history of IVDU, more proximal involvement of the upper limb, time between presentation and first debridement, pyrexia, dyspnoea and hypotension were not significantly associated with an increased risk of mortality.
Figure 4: Seven months post-operatively after split skin graft reconstruction demonstrating satisfactory cosmetic appearance and function.
Discussion
This study has shown that NF of the upper limb poses a significant mortality risk, particularly in the elderly. The foundation of treatment for NF is early and aggressive surgical debridement, initiation of broad spectrum antibiotics and intensive care support.10–14 The results presented here demonstrate of those that survive and obtain aggressive treatment, sound quality of life outcomes can be achieved.
Diagnosis is often delayed resulting in poor outcomes with a mortality rate in the upper limb in the range of 9–36%.2,9,15 Distinguishing NF from a simple soft tissue infection can be problematic and relies on a high index of suspicion. Early in the disease process, patients can appear relatively well, without features of systemic toxicity such as high-grade pyrexia and hypotension. Early findings of low-grade pyrexia, oedema, erythema and pain are present. Crepitus, suggesting gas formation in the deeper tissues as a result of anaerobic metabolism, is a classical but infrequent sign.2 Pain out of proportion to the clinical picture in conjunction with clinical acumen is a reliable sign assisting diagnosis.2,9
NF of the upper extremity is uncommon, affecting 10% of cases in a large 11-year retrospective review of all anatomical sites in a New Zealand based study.10 Given the paucity of published cases specifically of the upper limb, no convincing prognostic indicators have been identified. Cheng and colleagues demonstrated an altered level of consciousness on arrival to hospital as well as signs of respiratory distress were significant predictors of mortality in their retrospective review.2 Schecter and colleagues demonstrated a significant reduction in the length of hospital admission and number of debridements needed in patients undergoing radical debridement within 24 hours.15 No significant predictors of mortality were noted.
The results of this study have demonstrated significantly worse outcomes for older patients (48 [SD: 18] years in survivors and 80 [SD: 10] years in deceased) and those with hypertensive disease. Type 2 diabetes, although the most commonly encountered comorbidity in the current study population, was not significantly associated with mortality in this study. It is possible, however, with a larger sample size this trend would have likely lead to significance. Numerous authors have demonstrated risk factors significantly associated with mortality in studies of NF of all anatomical sites. Type 2 diabetes,16 heart disease,17 pre-existing renal impairment and gout11 have all been demonstrated as predictors of mortality in NF of all anatomical sites. McHenry et al showed that the average time from admission to operation in those who survived was 25 h versus 90 h in the non-survivors (both clinically and statistically significant).18 Tang and colleagues found significantly worse mortality with individuals suffering from more proximal involvement of a limb compared with distal sites such as the hand and foot.9
Three cases (20%) in the current study underwent radiological investigations (ultrasonography, USS ± computed tomography, CT/magnetic resonance imaging, MRI) ordered prior to first debridement. USS aided in excluding subcutaneous collections, however CT/MRI proved inconclusive. Although time to the operating room from presentation was longer in patients requiring radiology (79 hours) compared with those who did not (38 hours), this trend was not significant. No significant relationship was found between ordering of radiology, number of debridements or length of stay. Foreign bodies, abscesses and fluid collections can be easily demonstrated using sonography,19–21 however these features are not always present in NF. CT allows detection of subcutaneous and fascial oedema, gas formation, abscesses and foreign bodies.22 In cases of massive fluid collections along the fascia seen on CT or USS, NF can be suspected. Compared with MRI,23,24 USS and CT do not have as high accuracy for differentiation between cellulitis and NF because of their lower sensitivity in detecting deep fascial fluid. Although the treatment of choice due to its high sensitivity (100%), MRI is costly, not entirely specific (86%) and often unavailable in a timely manner allowing prompt diagnosis.25 Clinical acumen must remain to allow timely diagnosis and recognition of the need for surgical debridement.
Despite variation in reconstructive procedures that took place patients who retained their affected limb had generally satisfactory outcomes in terms of QuickDASH and PEM. As there were no survivors who underwent amputation (two cases) the functional outcome of these patients cannot be assessed and plausibly could have reduced the mean score.
The study is by its small sample size and retrospective nature, highlighting the scarcity of NF. Although a high proportion of our study, only three patients died limiting statistical analysis. Risk factors such as type 2 diabetes and a delay in time to first surgical debridement may have had an association with mortality as demonstrated by authors on other populations.
In conclusion, NF of the upper limb is an uncommon condition with significant mortality, especially in the elderly, requiring prompt recognition and early surgical management. Diagnosis remains clinical and an element of diagnostic acumen will allow prompt appropriate treatment to be initiated. This study has demonstrated sound outcomes in survivors of NF of the upper limb and high levels of patient satisfaction with treatment.
Summary
Abstract
Aim
Method
Results
Conclusion
Author Information
Acknowledgements
Correspondence
Correspondence Email
Competing Interests
1. Wong CH, Khin LW, Heng KS, Tan KC, Low CO. The LRINEC (Laboratory Risk Indicator for Necrotising fasciitis score): a tool for distinguishing necrotizing fasciitis from other soft tissue infections. Crit. Care Med. 2004; 32:1535–41.
2. Cheng N, Su Y, Kuo Y, Tai H, Tang Y. Factors Affecting the Mortality of Necrotising Fasciitis Involving the Upper Extremities. Surg Today. 2008; 38:1108–1113.
3. Bucca K, Spencer R, Orford N, Cattigan C, Athan E, McDonald A. Early diagnosis and treatment of necrotizing fasciitis can improve survival: an observational intensive care unit cohort study. ANZ J Surg. 2013 May; 83(5):365–70.
4. Bellapianta JM, Ljungquist K, Tobbin E, Uhl R. Necrotising fasciitis. J. Am. Acad. Orthop. Surg. 2009; 17:174–82.
5. Zacharias N, Velmahos GC, Salama A, et al. Diagnosis of necrotizing soft tissue infections by computed tomography. Arch. Surg. 2010; 145:452–5.
6. Kobayashi L, Konstantinidis A, Shackelford S, et al. Necrotising soft tissue infections: delayed surgical treatment is associated with increased of surgical debridement’s and morbidity. J. Trauma 2011; 71:1400–5.
7. Redman DP, Friedman B, Law E, Still JM. Experience with necrotizing fasciitis at a burn care center. South. Med J. 2003; 96:868–70.
8. Wong CH, Chang HC, Pasupathy S, Khin LW, Tan JL, Low CO. Necrotising fasciitis: clinical presentation, microbiology and determinants of mortality. J Bone Joint Surg Am 2003; 85-A:1454–60.
9. Tang WM, Ho PL, Fung KK, Yuen KY, Leong JC. Necrotising fasciitis of limb. J Bone Joint Surg Br 2001; 107:1684–93.
10. Kulasegaran, S. Cribb B, Vandal AC, McBride S, Holland D, MacCormick AD. Necrotising fasciitis: 11-year retrospective case review in South Auckland. ANZ Journal of Surgery. July 2015.
11. Mitchell A, Wiliams A, Dzendwoskyi P. Necrotising fasciitis: an 8.5-year retrospective case review in a New Zealand Intensive care unit. Crit. Care Resusc. 2011; 13:232–7.
12. Das D, Baker M, Venugopal K. Increasing incidence of necrotizing fasciitis in New Zealand: a nationwide study over 1990–2006. J. Infect. 2011; 63:429–33.
13. Misiakos EP, Bagias G, Patapis P, Sotiropoulos D, Kanavidis P, Machairas A. Current concepts in the management of necrotizing fasciitis. Front. Surg. 2014; 1:1–10.
14. Sopoaga F, Buckingham K, Paul C. Causes of excess hospitalizations among Pacific peoples in New Zealand: implications for primary care. J. Prim. Health Care 2010; 2:105–10.
15. Schecter W, Meyer A, Schecter G, Giuliano A, Newmeyer W, Kilgore E. Necrotising fasciitis of the upper extremity. J. Hand Surg. 1982; 7:15–20.
16. Wang J, Lim H. Necrotising fasciitis: either-year experience and literature review. Braz. J. Infect. Dis. 2014; 18:137–43.
17. Anaya D, Delinger E. Necrotising soft tissue infection: diagnosis and management. Clin. Infect. Dis. 2007; 44:705–10.
18. McHenry CR, Piotrowski JJ, Petrinic C. Determinants of mortality for necrotizing soft-tissue infections. Ann. Surg. 1995; 221:558–63.
19. Walshaw – Walshaw CF, Deans H. CT findings in necrotizing fasciitis: a report of four cases. Clin Radiol 1996; 51:429–432.
20. Kaplan PA, Matamoros A Jr, Anderson JC. Sonography of the musculoskeletal system. AJR 1990; 51:429–432.
21. Loyer EM, DuBrow RA, David CL, Coan JD, Eftekhari F. Imaging of superficial soft-tissue infections: sonographic findings in cases of cellulitis and abscess. AJR 1996; 166:149–152.
22. Fisher JR, Conway MJ, Takeshita RT, Sandoval MR. Necrotising fasciitis: importance of roentgenographic studies for soft-tissue gas. JAMA 1979; 241:803–806.
23. Rahmouni A, Chosidow O, Mathieu D. et al. MR Imaging in acute infectious cellulitis. Radiology 1994; 192:493–496.
24. Saiag P, LeBreoton C, Pavlovic M, Fouchard N, Delzant G, Bigot JM. Magnetic resonance imaging in adults presenting with severe acute infectious cellulitis. Arch Dermatol 1994; 130:1150–1158.
25. Schmid MR, Kossmann T, Duewell S. Differentiation of Necrotizing fasciitis and Cellulitis Using MR Imaging. AJR:170, March 1998.
For the PDF of this article,
contact nzmj@nzma.org.nz
Necrotising fasciitis of the upper limb: an Auckland experience
View Article PDF
Necrotising fasciitis (NF) is a severe and rapidly fulminating septic process, primarily involving subcutaneous and fascial tissues. It has the potential to spread precipitously to involve an entire limb resulting in significant soft tissue defects and in some cases amputation and death. The upper extremity is less commonly affected (6–27%) compared with other anatomical sites and the diagnosis is often challenging.1,2 Early surgical debridement is the single most important factor in determining outcome3–7 and delay in treatment adversely impacts mortality.8
Due to the rarity of upper extremity NF, its description in the literature has been limited to case reports, small studies or large studies of mixed anatomical sites which included the upper limb. Mortality rates for the upper extremity have been reported as high as 36%.9 Factors predicting mortality for NF of the upper extremity include altered level of consciousness and respiratory distress on presentation2 as well as more proximal involvement of a limb.9 NF has been shown to be twice as prevalent in the South Auckland population compared with the rest of the developed world.10 Investigation into these factors of the upper extremity is yet to be done on an Australasian population.
This study aimed to comment on the incidence and outcomes of NF of the upper limb in Auckland, New Zealand. It looked at the characteristics of patients with upper limb NF to assess whether any characteristics could be correlated with outcomes. The hypothesis was that an older age, history of immunosuppression and delay until first debridement would result in higher rates of morbidity and mortality.
Methods
A retrospective review of all patients treated with necrotising fasciitis of the upper limb at the Auckland Regional Centre for Plastic, Reconstructive and Hand Surgery between 1 January 2006 and 1 December 2015 was performed. Diagnosis was made intraoperatively by the surgical team with the presence of necrotic fascia removed easily with blunt dissection in conjunction with purulence resembling a ‘dishwater’ appearance (Figure 2, 3). Patient demographics, clinical features, laboratory and radiological investigations, surgical parameters, reconstruction methods and immediate and long-term outcomes were investigated. QuickDASH (Disabilities of Arm, Shoulder and Hand) and Patient Evaluation Measure (PEM) questionnaires (Figure 1) were used to evaluate subjective outcomes. Tests of association was carried out between each of the clinical characteristics and mortality, using Fisher exact test for the categorical variables and non-parametric test for the continuous variables.
Figure 1: Patient Evaluation Measure (PEM) questionnaire sections 2 and 3 utilised for this study.
Figure 2: Prior to first debridement, 43 hours after presentation. ‘Dishwater appearance noted with gentle blunt debridement’.
Figure 3: Dorsal forearm fascia during first debridement.
Results
Fifteen patients were identified. Mean follow-up time was 24 (standard deviation [SD]21) months. Mean age at admission was 54 (SD:21) years (Table 1). Forty-seven percent were NZ European, 40% Polynesian and 13% Māori. Positive smoking history was recorded in 40% of patients. The most common comorbidity seen was type 2 diabetes (40%). Only one case had a history of intravenous drug usage (IVDU). The most common initial site of symptomatology was the hand (60%) followed by the elbow (20%), forearm (13%) and chest wall (7%). Ninety-three percent of cases had positive tissue cultures of which the most frequently isolated organism was Streptococcus pyogenes (73%). Polymicrobial cultures were seen in 57%. The majority of patients initially received an antibiotic regime of intravenous Penicillin, Clindamycin and Gentamycin until a specific organism(s) was isolated. Mean time to the operating room from admission was 47 (SD: 84) hours. Patients underwent a mean of 3.4 debridements and 12 cases underwent reconstruction (11 split skin graft, one anterolateral thigh free flap). Reconstruction did not occur in three cases; two due to mortality and one healed satisfactorily by secondary intention. Mean length of hospital admission was 17.6 (SD:12.4) days.
Table 1: Univariate analysis.
Three patients (20%) died in our study, all due to disease specific causes. Two deceased cases were complicated by multi-organ dysfunction secondary to septicaemia. One deceased case was complicated by hospital-acquired pneumonia and septicaemia-induced arrhythmia with subsequent cardiac dysfunction. Univariate analysis (Table 1) demonstrated older age (p=0.017), hypertensive disease (p=0.044) and the need for amputation (p=0.029) were significantly associated with mortality. Requirement for amputation in the two cases indicated the difficulty in controlling the infection; correlating with more severe disease course as opposed to a lack of reconstructive options. Ethnicity, diabetes, smoking history, history of IVDU, more proximal involvement of the upper limb, time between presentation and first debridement, pyrexia, dyspnoea and hypotension were not significantly associated with an increased risk of mortality.
Figure 4: Seven months post-operatively after split skin graft reconstruction demonstrating satisfactory cosmetic appearance and function.
Discussion
This study has shown that NF of the upper limb poses a significant mortality risk, particularly in the elderly. The foundation of treatment for NF is early and aggressive surgical debridement, initiation of broad spectrum antibiotics and intensive care support.10–14 The results presented here demonstrate of those that survive and obtain aggressive treatment, sound quality of life outcomes can be achieved.
Diagnosis is often delayed resulting in poor outcomes with a mortality rate in the upper limb in the range of 9–36%.2,9,15 Distinguishing NF from a simple soft tissue infection can be problematic and relies on a high index of suspicion. Early in the disease process, patients can appear relatively well, without features of systemic toxicity such as high-grade pyrexia and hypotension. Early findings of low-grade pyrexia, oedema, erythema and pain are present. Crepitus, suggesting gas formation in the deeper tissues as a result of anaerobic metabolism, is a classical but infrequent sign.2 Pain out of proportion to the clinical picture in conjunction with clinical acumen is a reliable sign assisting diagnosis.2,9
NF of the upper extremity is uncommon, affecting 10% of cases in a large 11-year retrospective review of all anatomical sites in a New Zealand based study.10 Given the paucity of published cases specifically of the upper limb, no convincing prognostic indicators have been identified. Cheng and colleagues demonstrated an altered level of consciousness on arrival to hospital as well as signs of respiratory distress were significant predictors of mortality in their retrospective review.2 Schecter and colleagues demonstrated a significant reduction in the length of hospital admission and number of debridements needed in patients undergoing radical debridement within 24 hours.15 No significant predictors of mortality were noted.
The results of this study have demonstrated significantly worse outcomes for older patients (48 [SD: 18] years in survivors and 80 [SD: 10] years in deceased) and those with hypertensive disease. Type 2 diabetes, although the most commonly encountered comorbidity in the current study population, was not significantly associated with mortality in this study. It is possible, however, with a larger sample size this trend would have likely lead to significance. Numerous authors have demonstrated risk factors significantly associated with mortality in studies of NF of all anatomical sites. Type 2 diabetes,16 heart disease,17 pre-existing renal impairment and gout11 have all been demonstrated as predictors of mortality in NF of all anatomical sites. McHenry et al showed that the average time from admission to operation in those who survived was 25 h versus 90 h in the non-survivors (both clinically and statistically significant).18 Tang and colleagues found significantly worse mortality with individuals suffering from more proximal involvement of a limb compared with distal sites such as the hand and foot.9
Three cases (20%) in the current study underwent radiological investigations (ultrasonography, USS ± computed tomography, CT/magnetic resonance imaging, MRI) ordered prior to first debridement. USS aided in excluding subcutaneous collections, however CT/MRI proved inconclusive. Although time to the operating room from presentation was longer in patients requiring radiology (79 hours) compared with those who did not (38 hours), this trend was not significant. No significant relationship was found between ordering of radiology, number of debridements or length of stay. Foreign bodies, abscesses and fluid collections can be easily demonstrated using sonography,19–21 however these features are not always present in NF. CT allows detection of subcutaneous and fascial oedema, gas formation, abscesses and foreign bodies.22 In cases of massive fluid collections along the fascia seen on CT or USS, NF can be suspected. Compared with MRI,23,24 USS and CT do not have as high accuracy for differentiation between cellulitis and NF because of their lower sensitivity in detecting deep fascial fluid. Although the treatment of choice due to its high sensitivity (100%), MRI is costly, not entirely specific (86%) and often unavailable in a timely manner allowing prompt diagnosis.25 Clinical acumen must remain to allow timely diagnosis and recognition of the need for surgical debridement.
Despite variation in reconstructive procedures that took place patients who retained their affected limb had generally satisfactory outcomes in terms of QuickDASH and PEM. As there were no survivors who underwent amputation (two cases) the functional outcome of these patients cannot be assessed and plausibly could have reduced the mean score.
The study is by its small sample size and retrospective nature, highlighting the scarcity of NF. Although a high proportion of our study, only three patients died limiting statistical analysis. Risk factors such as type 2 diabetes and a delay in time to first surgical debridement may have had an association with mortality as demonstrated by authors on other populations.
In conclusion, NF of the upper limb is an uncommon condition with significant mortality, especially in the elderly, requiring prompt recognition and early surgical management. Diagnosis remains clinical and an element of diagnostic acumen will allow prompt appropriate treatment to be initiated. This study has demonstrated sound outcomes in survivors of NF of the upper limb and high levels of patient satisfaction with treatment.
Summary
Abstract
Aim
Method
Results
Conclusion
Author Information
Acknowledgements
Correspondence
Correspondence Email
Competing Interests
1. Wong CH, Khin LW, Heng KS, Tan KC, Low CO. The LRINEC (Laboratory Risk Indicator for Necrotising fasciitis score): a tool for distinguishing necrotizing fasciitis from other soft tissue infections. Crit. Care Med. 2004; 32:1535–41.
2. Cheng N, Su Y, Kuo Y, Tai H, Tang Y. Factors Affecting the Mortality of Necrotising Fasciitis Involving the Upper Extremities. Surg Today. 2008; 38:1108–1113.
3. Bucca K, Spencer R, Orford N, Cattigan C, Athan E, McDonald A. Early diagnosis and treatment of necrotizing fasciitis can improve survival: an observational intensive care unit cohort study. ANZ J Surg. 2013 May; 83(5):365–70.
4. Bellapianta JM, Ljungquist K, Tobbin E, Uhl R. Necrotising fasciitis. J. Am. Acad. Orthop. Surg. 2009; 17:174–82.
5. Zacharias N, Velmahos GC, Salama A, et al. Diagnosis of necrotizing soft tissue infections by computed tomography. Arch. Surg. 2010; 145:452–5.
6. Kobayashi L, Konstantinidis A, Shackelford S, et al. Necrotising soft tissue infections: delayed surgical treatment is associated with increased of surgical debridement’s and morbidity. J. Trauma 2011; 71:1400–5.
7. Redman DP, Friedman B, Law E, Still JM. Experience with necrotizing fasciitis at a burn care center. South. Med J. 2003; 96:868–70.
8. Wong CH, Chang HC, Pasupathy S, Khin LW, Tan JL, Low CO. Necrotising fasciitis: clinical presentation, microbiology and determinants of mortality. J Bone Joint Surg Am 2003; 85-A:1454–60.
9. Tang WM, Ho PL, Fung KK, Yuen KY, Leong JC. Necrotising fasciitis of limb. J Bone Joint Surg Br 2001; 107:1684–93.
10. Kulasegaran, S. Cribb B, Vandal AC, McBride S, Holland D, MacCormick AD. Necrotising fasciitis: 11-year retrospective case review in South Auckland. ANZ Journal of Surgery. July 2015.
11. Mitchell A, Wiliams A, Dzendwoskyi P. Necrotising fasciitis: an 8.5-year retrospective case review in a New Zealand Intensive care unit. Crit. Care Resusc. 2011; 13:232–7.
12. Das D, Baker M, Venugopal K. Increasing incidence of necrotizing fasciitis in New Zealand: a nationwide study over 1990–2006. J. Infect. 2011; 63:429–33.
13. Misiakos EP, Bagias G, Patapis P, Sotiropoulos D, Kanavidis P, Machairas A. Current concepts in the management of necrotizing fasciitis. Front. Surg. 2014; 1:1–10.
14. Sopoaga F, Buckingham K, Paul C. Causes of excess hospitalizations among Pacific peoples in New Zealand: implications for primary care. J. Prim. Health Care 2010; 2:105–10.
15. Schecter W, Meyer A, Schecter G, Giuliano A, Newmeyer W, Kilgore E. Necrotising fasciitis of the upper extremity. J. Hand Surg. 1982; 7:15–20.
16. Wang J, Lim H. Necrotising fasciitis: either-year experience and literature review. Braz. J. Infect. Dis. 2014; 18:137–43.
17. Anaya D, Delinger E. Necrotising soft tissue infection: diagnosis and management. Clin. Infect. Dis. 2007; 44:705–10.
18. McHenry CR, Piotrowski JJ, Petrinic C. Determinants of mortality for necrotizing soft-tissue infections. Ann. Surg. 1995; 221:558–63.
19. Walshaw – Walshaw CF, Deans H. CT findings in necrotizing fasciitis: a report of four cases. Clin Radiol 1996; 51:429–432.
20. Kaplan PA, Matamoros A Jr, Anderson JC. Sonography of the musculoskeletal system. AJR 1990; 51:429–432.
21. Loyer EM, DuBrow RA, David CL, Coan JD, Eftekhari F. Imaging of superficial soft-tissue infections: sonographic findings in cases of cellulitis and abscess. AJR 1996; 166:149–152.
22. Fisher JR, Conway MJ, Takeshita RT, Sandoval MR. Necrotising fasciitis: importance of roentgenographic studies for soft-tissue gas. JAMA 1979; 241:803–806.
23. Rahmouni A, Chosidow O, Mathieu D. et al. MR Imaging in acute infectious cellulitis. Radiology 1994; 192:493–496.
24. Saiag P, LeBreoton C, Pavlovic M, Fouchard N, Delzant G, Bigot JM. Magnetic resonance imaging in adults presenting with severe acute infectious cellulitis. Arch Dermatol 1994; 130:1150–1158.
25. Schmid MR, Kossmann T, Duewell S. Differentiation of Necrotizing fasciitis and Cellulitis Using MR Imaging. AJR:170, March 1998.
For the PDF of this article,
contact nzmj@nzma.org.nz
Necrotising fasciitis of the upper limb: an Auckland experience
View Article PDF
Necrotising fasciitis (NF) is a severe and rapidly fulminating septic process, primarily involving subcutaneous and fascial tissues. It has the potential to spread precipitously to involve an entire limb resulting in significant soft tissue defects and in some cases amputation and death. The upper extremity is less commonly affected (6–27%) compared with other anatomical sites and the diagnosis is often challenging.1,2 Early surgical debridement is the single most important factor in determining outcome3–7 and delay in treatment adversely impacts mortality.8
Due to the rarity of upper extremity NF, its description in the literature has been limited to case reports, small studies or large studies of mixed anatomical sites which included the upper limb. Mortality rates for the upper extremity have been reported as high as 36%.9 Factors predicting mortality for NF of the upper extremity include altered level of consciousness and respiratory distress on presentation2 as well as more proximal involvement of a limb.9 NF has been shown to be twice as prevalent in the South Auckland population compared with the rest of the developed world.10 Investigation into these factors of the upper extremity is yet to be done on an Australasian population.
This study aimed to comment on the incidence and outcomes of NF of the upper limb in Auckland, New Zealand. It looked at the characteristics of patients with upper limb NF to assess whether any characteristics could be correlated with outcomes. The hypothesis was that an older age, history of immunosuppression and delay until first debridement would result in higher rates of morbidity and mortality.
Methods
A retrospective review of all patients treated with necrotising fasciitis of the upper limb at the Auckland Regional Centre for Plastic, Reconstructive and Hand Surgery between 1 January 2006 and 1 December 2015 was performed. Diagnosis was made intraoperatively by the surgical team with the presence of necrotic fascia removed easily with blunt dissection in conjunction with purulence resembling a ‘dishwater’ appearance (Figure 2, 3). Patient demographics, clinical features, laboratory and radiological investigations, surgical parameters, reconstruction methods and immediate and long-term outcomes were investigated. QuickDASH (Disabilities of Arm, Shoulder and Hand) and Patient Evaluation Measure (PEM) questionnaires (Figure 1) were used to evaluate subjective outcomes. Tests of association was carried out between each of the clinical characteristics and mortality, using Fisher exact test for the categorical variables and non-parametric test for the continuous variables.
Figure 1: Patient Evaluation Measure (PEM) questionnaire sections 2 and 3 utilised for this study.
Figure 2: Prior to first debridement, 43 hours after presentation. ‘Dishwater appearance noted with gentle blunt debridement’.
Figure 3: Dorsal forearm fascia during first debridement.
Results
Fifteen patients were identified. Mean follow-up time was 24 (standard deviation [SD]21) months. Mean age at admission was 54 (SD:21) years (Table 1). Forty-seven percent were NZ European, 40% Polynesian and 13% Māori. Positive smoking history was recorded in 40% of patients. The most common comorbidity seen was type 2 diabetes (40%). Only one case had a history of intravenous drug usage (IVDU). The most common initial site of symptomatology was the hand (60%) followed by the elbow (20%), forearm (13%) and chest wall (7%). Ninety-three percent of cases had positive tissue cultures of which the most frequently isolated organism was Streptococcus pyogenes (73%). Polymicrobial cultures were seen in 57%. The majority of patients initially received an antibiotic regime of intravenous Penicillin, Clindamycin and Gentamycin until a specific organism(s) was isolated. Mean time to the operating room from admission was 47 (SD: 84) hours. Patients underwent a mean of 3.4 debridements and 12 cases underwent reconstruction (11 split skin graft, one anterolateral thigh free flap). Reconstruction did not occur in three cases; two due to mortality and one healed satisfactorily by secondary intention. Mean length of hospital admission was 17.6 (SD:12.4) days.
Table 1: Univariate analysis.
Three patients (20%) died in our study, all due to disease specific causes. Two deceased cases were complicated by multi-organ dysfunction secondary to septicaemia. One deceased case was complicated by hospital-acquired pneumonia and septicaemia-induced arrhythmia with subsequent cardiac dysfunction. Univariate analysis (Table 1) demonstrated older age (p=0.017), hypertensive disease (p=0.044) and the need for amputation (p=0.029) were significantly associated with mortality. Requirement for amputation in the two cases indicated the difficulty in controlling the infection; correlating with more severe disease course as opposed to a lack of reconstructive options. Ethnicity, diabetes, smoking history, history of IVDU, more proximal involvement of the upper limb, time between presentation and first debridement, pyrexia, dyspnoea and hypotension were not significantly associated with an increased risk of mortality.
Figure 4: Seven months post-operatively after split skin graft reconstruction demonstrating satisfactory cosmetic appearance and function.
Discussion
This study has shown that NF of the upper limb poses a significant mortality risk, particularly in the elderly. The foundation of treatment for NF is early and aggressive surgical debridement, initiation of broad spectrum antibiotics and intensive care support.10–14 The results presented here demonstrate of those that survive and obtain aggressive treatment, sound quality of life outcomes can be achieved.
Diagnosis is often delayed resulting in poor outcomes with a mortality rate in the upper limb in the range of 9–36%.2,9,15 Distinguishing NF from a simple soft tissue infection can be problematic and relies on a high index of suspicion. Early in the disease process, patients can appear relatively well, without features of systemic toxicity such as high-grade pyrexia and hypotension. Early findings of low-grade pyrexia, oedema, erythema and pain are present. Crepitus, suggesting gas formation in the deeper tissues as a result of anaerobic metabolism, is a classical but infrequent sign.2 Pain out of proportion to the clinical picture in conjunction with clinical acumen is a reliable sign assisting diagnosis.2,9
NF of the upper extremity is uncommon, affecting 10% of cases in a large 11-year retrospective review of all anatomical sites in a New Zealand based study.10 Given the paucity of published cases specifically of the upper limb, no convincing prognostic indicators have been identified. Cheng and colleagues demonstrated an altered level of consciousness on arrival to hospital as well as signs of respiratory distress were significant predictors of mortality in their retrospective review.2 Schecter and colleagues demonstrated a significant reduction in the length of hospital admission and number of debridements needed in patients undergoing radical debridement within 24 hours.15 No significant predictors of mortality were noted.
The results of this study have demonstrated significantly worse outcomes for older patients (48 [SD: 18] years in survivors and 80 [SD: 10] years in deceased) and those with hypertensive disease. Type 2 diabetes, although the most commonly encountered comorbidity in the current study population, was not significantly associated with mortality in this study. It is possible, however, with a larger sample size this trend would have likely lead to significance. Numerous authors have demonstrated risk factors significantly associated with mortality in studies of NF of all anatomical sites. Type 2 diabetes,16 heart disease,17 pre-existing renal impairment and gout11 have all been demonstrated as predictors of mortality in NF of all anatomical sites. McHenry et al showed that the average time from admission to operation in those who survived was 25 h versus 90 h in the non-survivors (both clinically and statistically significant).18 Tang and colleagues found significantly worse mortality with individuals suffering from more proximal involvement of a limb compared with distal sites such as the hand and foot.9
Three cases (20%) in the current study underwent radiological investigations (ultrasonography, USS ± computed tomography, CT/magnetic resonance imaging, MRI) ordered prior to first debridement. USS aided in excluding subcutaneous collections, however CT/MRI proved inconclusive. Although time to the operating room from presentation was longer in patients requiring radiology (79 hours) compared with those who did not (38 hours), this trend was not significant. No significant relationship was found between ordering of radiology, number of debridements or length of stay. Foreign bodies, abscesses and fluid collections can be easily demonstrated using sonography,19–21 however these features are not always present in NF. CT allows detection of subcutaneous and fascial oedema, gas formation, abscesses and foreign bodies.22 In cases of massive fluid collections along the fascia seen on CT or USS, NF can be suspected. Compared with MRI,23,24 USS and CT do not have as high accuracy for differentiation between cellulitis and NF because of their lower sensitivity in detecting deep fascial fluid. Although the treatment of choice due to its high sensitivity (100%), MRI is costly, not entirely specific (86%) and often unavailable in a timely manner allowing prompt diagnosis.25 Clinical acumen must remain to allow timely diagnosis and recognition of the need for surgical debridement.
Despite variation in reconstructive procedures that took place patients who retained their affected limb had generally satisfactory outcomes in terms of QuickDASH and PEM. As there were no survivors who underwent amputation (two cases) the functional outcome of these patients cannot be assessed and plausibly could have reduced the mean score.
The study is by its small sample size and retrospective nature, highlighting the scarcity of NF. Although a high proportion of our study, only three patients died limiting statistical analysis. Risk factors such as type 2 diabetes and a delay in time to first surgical debridement may have had an association with mortality as demonstrated by authors on other populations.
In conclusion, NF of the upper limb is an uncommon condition with significant mortality, especially in the elderly, requiring prompt recognition and early surgical management. Diagnosis remains clinical and an element of diagnostic acumen will allow prompt appropriate treatment to be initiated. This study has demonstrated sound outcomes in survivors of NF of the upper limb and high levels of patient satisfaction with treatment.
Summary
Abstract
Aim
Method
Results
Conclusion
Author Information
Acknowledgements
Correspondence
Correspondence Email
Competing Interests
1. Wong CH, Khin LW, Heng KS, Tan KC, Low CO. The LRINEC (Laboratory Risk Indicator for Necrotising fasciitis score): a tool for distinguishing necrotizing fasciitis from other soft tissue infections. Crit. Care Med. 2004; 32:1535–41.
2. Cheng N, Su Y, Kuo Y, Tai H, Tang Y. Factors Affecting the Mortality of Necrotising Fasciitis Involving the Upper Extremities. Surg Today. 2008; 38:1108–1113.
3. Bucca K, Spencer R, Orford N, Cattigan C, Athan E, McDonald A. Early diagnosis and treatment of necrotizing fasciitis can improve survival: an observational intensive care unit cohort study. ANZ J Surg. 2013 May; 83(5):365–70.
4. Bellapianta JM, Ljungquist K, Tobbin E, Uhl R. Necrotising fasciitis. J. Am. Acad. Orthop. Surg. 2009; 17:174–82.
5. Zacharias N, Velmahos GC, Salama A, et al. Diagnosis of necrotizing soft tissue infections by computed tomography. Arch. Surg. 2010; 145:452–5.
6. Kobayashi L, Konstantinidis A, Shackelford S, et al. Necrotising soft tissue infections: delayed surgical treatment is associated with increased of surgical debridement’s and morbidity. J. Trauma 2011; 71:1400–5.
7. Redman DP, Friedman B, Law E, Still JM. Experience with necrotizing fasciitis at a burn care center. South. Med J. 2003; 96:868–70.
8. Wong CH, Chang HC, Pasupathy S, Khin LW, Tan JL, Low CO. Necrotising fasciitis: clinical presentation, microbiology and determinants of mortality. J Bone Joint Surg Am 2003; 85-A:1454–60.
9. Tang WM, Ho PL, Fung KK, Yuen KY, Leong JC. Necrotising fasciitis of limb. J Bone Joint Surg Br 2001; 107:1684–93.
10. Kulasegaran, S. Cribb B, Vandal AC, McBride S, Holland D, MacCormick AD. Necrotising fasciitis: 11-year retrospective case review in South Auckland. ANZ Journal of Surgery. July 2015.
11. Mitchell A, Wiliams A, Dzendwoskyi P. Necrotising fasciitis: an 8.5-year retrospective case review in a New Zealand Intensive care unit. Crit. Care Resusc. 2011; 13:232–7.
12. Das D, Baker M, Venugopal K. Increasing incidence of necrotizing fasciitis in New Zealand: a nationwide study over 1990–2006. J. Infect. 2011; 63:429–33.
13. Misiakos EP, Bagias G, Patapis P, Sotiropoulos D, Kanavidis P, Machairas A. Current concepts in the management of necrotizing fasciitis. Front. Surg. 2014; 1:1–10.
14. Sopoaga F, Buckingham K, Paul C. Causes of excess hospitalizations among Pacific peoples in New Zealand: implications for primary care. J. Prim. Health Care 2010; 2:105–10.
15. Schecter W, Meyer A, Schecter G, Giuliano A, Newmeyer W, Kilgore E. Necrotising fasciitis of the upper extremity. J. Hand Surg. 1982; 7:15–20.
16. Wang J, Lim H. Necrotising fasciitis: either-year experience and literature review. Braz. J. Infect. Dis. 2014; 18:137–43.
17. Anaya D, Delinger E. Necrotising soft tissue infection: diagnosis and management. Clin. Infect. Dis. 2007; 44:705–10.
18. McHenry CR, Piotrowski JJ, Petrinic C. Determinants of mortality for necrotizing soft-tissue infections. Ann. Surg. 1995; 221:558–63.
19. Walshaw – Walshaw CF, Deans H. CT findings in necrotizing fasciitis: a report of four cases. Clin Radiol 1996; 51:429–432.
20. Kaplan PA, Matamoros A Jr, Anderson JC. Sonography of the musculoskeletal system. AJR 1990; 51:429–432.
21. Loyer EM, DuBrow RA, David CL, Coan JD, Eftekhari F. Imaging of superficial soft-tissue infections: sonographic findings in cases of cellulitis and abscess. AJR 1996; 166:149–152.
22. Fisher JR, Conway MJ, Takeshita RT, Sandoval MR. Necrotising fasciitis: importance of roentgenographic studies for soft-tissue gas. JAMA 1979; 241:803–806.
23. Rahmouni A, Chosidow O, Mathieu D. et al. MR Imaging in acute infectious cellulitis. Radiology 1994; 192:493–496.
24. Saiag P, LeBreoton C, Pavlovic M, Fouchard N, Delzant G, Bigot JM. Magnetic resonance imaging in adults presenting with severe acute infectious cellulitis. Arch Dermatol 1994; 130:1150–1158.
25. Schmid MR, Kossmann T, Duewell S. Differentiation of Necrotizing fasciitis and Cellulitis Using MR Imaging. AJR:170, March 1998.
Contact diana@nzma.org.nz
for the PDF of this article
Necrotising fasciitis of the upper limb: an Auckland experience
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Necrotising fasciitis (NF) is a severe and rapidly fulminating septic process, primarily involving subcutaneous and fascial tissues. It has the potential to spread precipitously to involve an entire limb resulting in significant soft tissue defects and in some cases amputation and death. The upper extremity is less commonly affected (6–27%) compared with other anatomical sites and the diagnosis is often challenging.1,2 Early surgical debridement is the single most important factor in determining outcome3–7 and delay in treatment adversely impacts mortality.8
Due to the rarity of upper extremity NF, its description in the literature has been limited to case reports, small studies or large studies of mixed anatomical sites which included the upper limb. Mortality rates for the upper extremity have been reported as high as 36%.9 Factors predicting mortality for NF of the upper extremity include altered level of consciousness and respiratory distress on presentation2 as well as more proximal involvement of a limb.9 NF has been shown to be twice as prevalent in the South Auckland population compared with the rest of the developed world.10 Investigation into these factors of the upper extremity is yet to be done on an Australasian population.
This study aimed to comment on the incidence and outcomes of NF of the upper limb in Auckland, New Zealand. It looked at the characteristics of patients with upper limb NF to assess whether any characteristics could be correlated with outcomes. The hypothesis was that an older age, history of immunosuppression and delay until first debridement would result in higher rates of morbidity and mortality.
Methods
A retrospective review of all patients treated with necrotising fasciitis of the upper limb at the Auckland Regional Centre for Plastic, Reconstructive and Hand Surgery between 1 January 2006 and 1 December 2015 was performed. Diagnosis was made intraoperatively by the surgical team with the presence of necrotic fascia removed easily with blunt dissection in conjunction with purulence resembling a ‘dishwater’ appearance (Figure 2, 3). Patient demographics, clinical features, laboratory and radiological investigations, surgical parameters, reconstruction methods and immediate and long-term outcomes were investigated. QuickDASH (Disabilities of Arm, Shoulder and Hand) and Patient Evaluation Measure (PEM) questionnaires (Figure 1) were used to evaluate subjective outcomes. Tests of association was carried out between each of the clinical characteristics and mortality, using Fisher exact test for the categorical variables and non-parametric test for the continuous variables.
Figure 1: Patient Evaluation Measure (PEM) questionnaire sections 2 and 3 utilised for this study.
Figure 2: Prior to first debridement, 43 hours after presentation. ‘Dishwater appearance noted with gentle blunt debridement’.
Figure 3: Dorsal forearm fascia during first debridement.
Results
Fifteen patients were identified. Mean follow-up time was 24 (standard deviation [SD]21) months. Mean age at admission was 54 (SD:21) years (Table 1). Forty-seven percent were NZ European, 40% Polynesian and 13% Māori. Positive smoking history was recorded in 40% of patients. The most common comorbidity seen was type 2 diabetes (40%). Only one case had a history of intravenous drug usage (IVDU). The most common initial site of symptomatology was the hand (60%) followed by the elbow (20%), forearm (13%) and chest wall (7%). Ninety-three percent of cases had positive tissue cultures of which the most frequently isolated organism was Streptococcus pyogenes (73%). Polymicrobial cultures were seen in 57%. The majority of patients initially received an antibiotic regime of intravenous Penicillin, Clindamycin and Gentamycin until a specific organism(s) was isolated. Mean time to the operating room from admission was 47 (SD: 84) hours. Patients underwent a mean of 3.4 debridements and 12 cases underwent reconstruction (11 split skin graft, one anterolateral thigh free flap). Reconstruction did not occur in three cases; two due to mortality and one healed satisfactorily by secondary intention. Mean length of hospital admission was 17.6 (SD:12.4) days.
Table 1: Univariate analysis.
Three patients (20%) died in our study, all due to disease specific causes. Two deceased cases were complicated by multi-organ dysfunction secondary to septicaemia. One deceased case was complicated by hospital-acquired pneumonia and septicaemia-induced arrhythmia with subsequent cardiac dysfunction. Univariate analysis (Table 1) demonstrated older age (p=0.017), hypertensive disease (p=0.044) and the need for amputation (p=0.029) were significantly associated with mortality. Requirement for amputation in the two cases indicated the difficulty in controlling the infection; correlating with more severe disease course as opposed to a lack of reconstructive options. Ethnicity, diabetes, smoking history, history of IVDU, more proximal involvement of the upper limb, time between presentation and first debridement, pyrexia, dyspnoea and hypotension were not significantly associated with an increased risk of mortality.
Figure 4: Seven months post-operatively after split skin graft reconstruction demonstrating satisfactory cosmetic appearance and function.
Discussion
This study has shown that NF of the upper limb poses a significant mortality risk, particularly in the elderly. The foundation of treatment for NF is early and aggressive surgical debridement, initiation of broad spectrum antibiotics and intensive care support.10–14 The results presented here demonstrate of those that survive and obtain aggressive treatment, sound quality of life outcomes can be achieved.
Diagnosis is often delayed resulting in poor outcomes with a mortality rate in the upper limb in the range of 9–36%.2,9,15 Distinguishing NF from a simple soft tissue infection can be problematic and relies on a high index of suspicion. Early in the disease process, patients can appear relatively well, without features of systemic toxicity such as high-grade pyrexia and hypotension. Early findings of low-grade pyrexia, oedema, erythema and pain are present. Crepitus, suggesting gas formation in the deeper tissues as a result of anaerobic metabolism, is a classical but infrequent sign.2 Pain out of proportion to the clinical picture in conjunction with clinical acumen is a reliable sign assisting diagnosis.2,9
NF of the upper extremity is uncommon, affecting 10% of cases in a large 11-year retrospective review of all anatomical sites in a New Zealand based study.10 Given the paucity of published cases specifically of the upper limb, no convincing prognostic indicators have been identified. Cheng and colleagues demonstrated an altered level of consciousness on arrival to hospital as well as signs of respiratory distress were significant predictors of mortality in their retrospective review.2 Schecter and colleagues demonstrated a significant reduction in the length of hospital admission and number of debridements needed in patients undergoing radical debridement within 24 hours.15 No significant predictors of mortality were noted.
The results of this study have demonstrated significantly worse outcomes for older patients (48 [SD: 18] years in survivors and 80 [SD: 10] years in deceased) and those with hypertensive disease. Type 2 diabetes, although the most commonly encountered comorbidity in the current study population, was not significantly associated with mortality in this study. It is possible, however, with a larger sample size this trend would have likely lead to significance. Numerous authors have demonstrated risk factors significantly associated with mortality in studies of NF of all anatomical sites. Type 2 diabetes,16 heart disease,17 pre-existing renal impairment and gout11 have all been demonstrated as predictors of mortality in NF of all anatomical sites. McHenry et al showed that the average time from admission to operation in those who survived was 25 h versus 90 h in the non-survivors (both clinically and statistically significant).18 Tang and colleagues found significantly worse mortality with individuals suffering from more proximal involvement of a limb compared with distal sites such as the hand and foot.9
Three cases (20%) in the current study underwent radiological investigations (ultrasonography, USS ± computed tomography, CT/magnetic resonance imaging, MRI) ordered prior to first debridement. USS aided in excluding subcutaneous collections, however CT/MRI proved inconclusive. Although time to the operating room from presentation was longer in patients requiring radiology (79 hours) compared with those who did not (38 hours), this trend was not significant. No significant relationship was found between ordering of radiology, number of debridements or length of stay. Foreign bodies, abscesses and fluid collections can be easily demonstrated using sonography,19–21 however these features are not always present in NF. CT allows detection of subcutaneous and fascial oedema, gas formation, abscesses and foreign bodies.22 In cases of massive fluid collections along the fascia seen on CT or USS, NF can be suspected. Compared with MRI,23,24 USS and CT do not have as high accuracy for differentiation between cellulitis and NF because of their lower sensitivity in detecting deep fascial fluid. Although the treatment of choice due to its high sensitivity (100%), MRI is costly, not entirely specific (86%) and often unavailable in a timely manner allowing prompt diagnosis.25 Clinical acumen must remain to allow timely diagnosis and recognition of the need for surgical debridement.
Despite variation in reconstructive procedures that took place patients who retained their affected limb had generally satisfactory outcomes in terms of QuickDASH and PEM. As there were no survivors who underwent amputation (two cases) the functional outcome of these patients cannot be assessed and plausibly could have reduced the mean score.
The study is by its small sample size and retrospective nature, highlighting the scarcity of NF. Although a high proportion of our study, only three patients died limiting statistical analysis. Risk factors such as type 2 diabetes and a delay in time to first surgical debridement may have had an association with mortality as demonstrated by authors on other populations.
In conclusion, NF of the upper limb is an uncommon condition with significant mortality, especially in the elderly, requiring prompt recognition and early surgical management. Diagnosis remains clinical and an element of diagnostic acumen will allow prompt appropriate treatment to be initiated. This study has demonstrated sound outcomes in survivors of NF of the upper limb and high levels of patient satisfaction with treatment.
Summary
Abstract
Aim
Method
Results
Conclusion
Author Information
Acknowledgements
Correspondence
Correspondence Email
Competing Interests
1. Wong CH, Khin LW, Heng KS, Tan KC, Low CO. The LRINEC (Laboratory Risk Indicator for Necrotising fasciitis score): a tool for distinguishing necrotizing fasciitis from other soft tissue infections. Crit. Care Med. 2004; 32:1535–41.
2. Cheng N, Su Y, Kuo Y, Tai H, Tang Y. Factors Affecting the Mortality of Necrotising Fasciitis Involving the Upper Extremities. Surg Today. 2008; 38:1108–1113.
3. Bucca K, Spencer R, Orford N, Cattigan C, Athan E, McDonald A. Early diagnosis and treatment of necrotizing fasciitis can improve survival: an observational intensive care unit cohort study. ANZ J Surg. 2013 May; 83(5):365–70.
4. Bellapianta JM, Ljungquist K, Tobbin E, Uhl R. Necrotising fasciitis. J. Am. Acad. Orthop. Surg. 2009; 17:174–82.
5. Zacharias N, Velmahos GC, Salama A, et al. Diagnosis of necrotizing soft tissue infections by computed tomography. Arch. Surg. 2010; 145:452–5.
6. Kobayashi L, Konstantinidis A, Shackelford S, et al. Necrotising soft tissue infections: delayed surgical treatment is associated with increased of surgical debridement’s and morbidity. J. Trauma 2011; 71:1400–5.
7. Redman DP, Friedman B, Law E, Still JM. Experience with necrotizing fasciitis at a burn care center. South. Med J. 2003; 96:868–70.
8. Wong CH, Chang HC, Pasupathy S, Khin LW, Tan JL, Low CO. Necrotising fasciitis: clinical presentation, microbiology and determinants of mortality. J Bone Joint Surg Am 2003; 85-A:1454–60.
9. Tang WM, Ho PL, Fung KK, Yuen KY, Leong JC. Necrotising fasciitis of limb. J Bone Joint Surg Br 2001; 107:1684–93.
10. Kulasegaran, S. Cribb B, Vandal AC, McBride S, Holland D, MacCormick AD. Necrotising fasciitis: 11-year retrospective case review in South Auckland. ANZ Journal of Surgery. July 2015.
11. Mitchell A, Wiliams A, Dzendwoskyi P. Necrotising fasciitis: an 8.5-year retrospective case review in a New Zealand Intensive care unit. Crit. Care Resusc. 2011; 13:232–7.
12. Das D, Baker M, Venugopal K. Increasing incidence of necrotizing fasciitis in New Zealand: a nationwide study over 1990–2006. J. Infect. 2011; 63:429–33.
13. Misiakos EP, Bagias G, Patapis P, Sotiropoulos D, Kanavidis P, Machairas A. Current concepts in the management of necrotizing fasciitis. Front. Surg. 2014; 1:1–10.
14. Sopoaga F, Buckingham K, Paul C. Causes of excess hospitalizations among Pacific peoples in New Zealand: implications for primary care. J. Prim. Health Care 2010; 2:105–10.
15. Schecter W, Meyer A, Schecter G, Giuliano A, Newmeyer W, Kilgore E. Necrotising fasciitis of the upper extremity. J. Hand Surg. 1982; 7:15–20.
16. Wang J, Lim H. Necrotising fasciitis: either-year experience and literature review. Braz. J. Infect. Dis. 2014; 18:137–43.
17. Anaya D, Delinger E. Necrotising soft tissue infection: diagnosis and management. Clin. Infect. Dis. 2007; 44:705–10.
18. McHenry CR, Piotrowski JJ, Petrinic C. Determinants of mortality for necrotizing soft-tissue infections. Ann. Surg. 1995; 221:558–63.
19. Walshaw – Walshaw CF, Deans H. CT findings in necrotizing fasciitis: a report of four cases. Clin Radiol 1996; 51:429–432.
20. Kaplan PA, Matamoros A Jr, Anderson JC. Sonography of the musculoskeletal system. AJR 1990; 51:429–432.
21. Loyer EM, DuBrow RA, David CL, Coan JD, Eftekhari F. Imaging of superficial soft-tissue infections: sonographic findings in cases of cellulitis and abscess. AJR 1996; 166:149–152.
22. Fisher JR, Conway MJ, Takeshita RT, Sandoval MR. Necrotising fasciitis: importance of roentgenographic studies for soft-tissue gas. JAMA 1979; 241:803–806.
23. Rahmouni A, Chosidow O, Mathieu D. et al. MR Imaging in acute infectious cellulitis. Radiology 1994; 192:493–496.
24. Saiag P, LeBreoton C, Pavlovic M, Fouchard N, Delzant G, Bigot JM. Magnetic resonance imaging in adults presenting with severe acute infectious cellulitis. Arch Dermatol 1994; 130:1150–1158.
25. Schmid MR, Kossmann T, Duewell S. Differentiation of Necrotizing fasciitis and Cellulitis Using MR Imaging. AJR:170, March 1998.
Contact diana@nzma.org.nz
for the PDF of this article
Necrotising fasciitis of the upper limb: an Auckland experience
Necrotising fasciitis (NF) is a severe and rapidly fulminating septic process, primarily involving subcutaneous and fascial tissues. It has the potential to spread precipitously to involve an entire limb resulting in significant soft tissue defects and in some cases amputation and death.
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