Rev. bras. ortop. vol.49 número1

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r e v b r a s o r t o p . 2014;49(1):78–81

w w w . r b o . o r g . b r

Case

Report

Necrotizing

fasciitis

after

internal

fixation

of

fracture

of

femoral

trochanteric

夽

,

夽夽

Leandro

Emílio

Nascimento

Santos

a,∗

,

Robinson

Esteves

Santos

Pires

a,b

,

Leonardo

Brandão

Figueiredo

a

_,

_Eduardo

_Augusto

_Marques

_Soares

a

a_Hospital_Felício_Rocho,_Belo_Horizonte,_MG,_Brazil

b_Hospital_das_Clínicas_da_Universidade_Federal_de_Minas_Gerais,_Belo_Horizonte,_MG,_Brazil

a

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t

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c

l

e

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n

f

o

Articlehistory:

Received6December2012

Accepted22March2013

Keywords:

Necrotizingfasciitis

Infection

Hipfractures

Femoralfractures

a

b

s

t

r

a

c

t

Necrotizingfasciitisisarareandpotentiallylethalsofttissueinfection.Wereportacase

oftrochantericfemurfractureinapatientwhounderwentfracturefixationanddeveloped

necrotizingfasciitis.Aliteraturereviewonthetopicwillbeaddressed.

Ltda.Allrightsreserved.

Fasciíte

necrosante

pós-osteossíntese

de

fratura

transtrocantérica

do

fêmur

Palavras-chave:

Fasciítenecrosante

Infecc¸ão

Fraturasdoquadril

Fraturasdofêmur

r

e

s

u

m

o

Afasciítenecrosanteéumararaepotencialmenteletalinfecc¸ãodepartesmoles.Aseguir,

descreveremosocasodeumapacienteportadoradefraturatranstrocantéricadofêmurque

evoluiucomfasciítenecrosanteapósaosteossíntesedafratura.Umarevisãodaliteratura

acercadotemaseráabordada.

Ltda.Todososdireitosreservados.

Introduction

Necrotizing fasciitis is a rare infection, misdiagnosed as a

benign infection. The physician must have a high degree

夽

Pleasecitethisarticleas:SantosLEN,PiresRES,FigueiredoLB,SoaresEAM.Fasciítenecrosantepós-osteossíntesedefratura

transtro-cantéricadofêmur.RevBrasOrtop.2014;49:78–81.

夽夽

StudyconductedatHospitalFelícioRocho,BeloHorizonte,MG,Brazil.

∗ _{Corresponding}_author_.

E-mail:leandroens@hotmail.com(L.E.N.Santos).

ofclinicalsuspicionforthe establishmentofanimmediate

diagnosis/treatment.Themostimportantvariableinfluencing

mortalityisthetimeofsurgicaldebridement.

Orthopedic surgeons are often the first to evaluate

patients with necrotizing fasciitis and therefore must be

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rev bras ortop.2014;49(1):78–81

79

knowledgeable of the clinical presentation and treatment.

Timelydiagnosis,surgicaldebridementandbroad-spectrum

parenteralantibiotictherapyarethekeystopropertreatment.

Theobjectiveofthisstudywastodescribethefatalcourse

ofapatientwhodevelopednecrotizingfasciitisafter

osteosyn-thesisoftranstrochantericfractureandtoreviewtheliterature

ofthisseriousinfection.

Case

report

Seventy-oneyearoldfemalewithahistoryoffallinginthe

bathroom. The patient was in pain, unable to walk, with

shortening,externalrotationandlimitedrangeofmotionof

the left leg.Presented witharterialhypertension, diabetes,

congestiveheartfailure,livercirrhosis,schistosomiasiswith

portalhypertension and thrombocytopenia. Radiographsof

thepelvisandlefthipshowedanunstabletranstrochanteric

fracture(31-A2.2/AO-ASIF).

Thepatientwasoperatedonthefourthdayof

hospitaliza-tionafterherreleaseofthemedicalclinic.Relativestabilityof

thefracture(osteosynthesiswithDHSscrew)and

postopera-tivecontrolintheICUwereobtained.

Onthe second daypostoperatively,thepatient was

dis-chargedfromtheICUandstartedmotorphysicaltherapywith

progressivepartialloadwithwalker.Shewasdischargedon

theeighthhospitalday.

Sixdaysafterdischarge,thepatientreturnedtothe

hospi-talcomplainingofpaininherleftleg,withedema,ecchymosis

and swellingofthe left calf.Theduplex scanofthe lower

limbsdepicteddeepveinthrombosis(DVT)intheleftlower

limb.

AnticoagulationwithenoxaparinSC,followedbywarfarin

PO,wasinitiated.

Aftertwodays,thepatientreportedpersistentpaininthe

medialaspectofherleftthigh,withfever(38◦_C)._Absence_of

skinchangesinthewound.

Laboratorytestswererequested:hemoglobin:7.5g/dL,total

leukocyte:2400mm–3_(bands:_7%,_segmented:_82%);_platelets:

46,000mm−3_,_RNI_1.94;_APTT:_41/26,_PCR:_28.7_mg/dL.

Progression the next day with hypotension (BP:

80×40mmHg), prostration and appearance of blisters on

the medialaspect of the left thigh. Absence ofpain relief

withtheuseofopioids.Startedempiricalantibiotictherapy

(meropenem),withnoimprovement.

Suspicionofnecrotizingfasciitis becauseofseverepain,

rapidappearanceofbullouslesionsinherleftthighand

refrac-torinesstoanalgesia.

Indicationofdebridement oftheleftleg,butthepatient

hadblooddyscrasia(INR7.36andPTTA73/26).

Changing antibiotics to intravenous tigecycline. The

patientwasreferredonanemergencybasistotheoperating

roomforwideleftlegfasciotomy,surgicaldebridementand

collectionofmaterialforanalysis(Figs.1–3).

Occurrenceofseveresepticshockrefractorytotheuseof

amines.Thepatienteventuallydied.

Theresultsofbloodculturesandsamplescollectedduring

surgery identified multiresistant A. baumannii/haemolyticus.

The germ was only sensitive to

trimethoprim-sulfamethoxazole,tetracyclineandtigecycline.

Fig.1–Necrotizingfasciitisinleftleg.

Fig.2–Anterioraspectoftheleftleg.Extensivenecrosis andpresenceofblisters.

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rev bras ortop.2014;49(1):78–81

Discussion

Necrotizingfasciitiswasdescribedin1871bytheU.S.Army

surgeonJosephJones.In1883,Fournieridentifiednecrotizing

fasciitisthataffectstheperineumandexternalgenitalia.But

itwasBenWilson,in1952,whodescribedthesuperficialfascia

andsubcutaneousnecrosis.

Necrotizingfasciitisfollowsaninjurytotheepidermis.In

45%ofcases,itisnotpossibleidentifythesiteoftheinitial

injury.1–3 _The_extremities_are _the _most _commonly_affected

local,buttheinvolvementofthetrunkandperineumisrelated

tothehighmortalityrate.4,5

Patientsover65yearsoldhavethehighestincidenceofthe

disease.1

Initially, the disease presentswith alocal edema.

How-ever,withtheinvolvementofthesurroundingtissues,local

toxicityistriggeredandsimulatesacellulitis.Butthepatient

presentswithseverepain,disproportionatetotheskinlesion.

Theprogressionofthemarginsoferythemaatgreaterthan

1cm/hspeedisanimportantsignaltothediagnosis inthe

earlystagesofnecrotizingfasciitis.6_With_the_evolution_of_the

underlyingnecroticprocess,serousblisterspossiblybecoming

hemorrhagiccanbeobserved.

Usually,fever,chills,hypotension,tachycardia,andaltered

levelofconsciousnessarepresent.2,6

Acuterenalfailureispresentin35%ofpatients,

coagulopa-thyin29%,acuterespiratoryfailurein14%,andbacteremiain

46%.7

Theburning painisthemostprominentsymptom,that

canbeobservedinalmost100%ofpatientswithnecrotizing

fasciitis.8

Thediagnosis is mainly clinical;it isessential that the

physicianhasahighdegreeofsuspicion.Theaveragetime

betweenonsetofsymptomsanddiagnosisis2-4days.9

WBC count>15,400cells/mm3 _and _serum _level _of

sodium<135mmol/Lhaveasensitivityof90%fornecrotizing

fasciitis. Thespecificity is 76% and the positive predictive

valueis26%,andthatonlyservestoexcludethedisease.10

Phosphocreatinlevels>600IU/L have58%sensitivityand

95%specificity.11

MRIhashighsensitivity(93–100%)fordiagnosis.Liquefied

tissueinflammationandedemaaroundthefasciaaredetected

byanincreasedsignalonT2-weightedimagesandabsenceof

attenuationofgadoliniuminT1.

“Thefingertest”isasimpleprocedure,doneunderlocal

anesthesia.The surgeon makesan incision of 2cm tothe

deepfascia,andhis/herglovedfingerisinserted.The

pres-enceofliquefiedsubcutaneoustissue,absenceofbleedingand

pooradherenceofsubcutaneoustissueduringblunt

dissec-tiondefineapositivetest.Asampleoftissuemustberesected

andsenttobacterioscopy,cultureandanatomopathological

examination.

Histologically,necrotizingfasciitisischaracterizedby

sup-purativefocalnecrosisoffascia,fatandnerves,edemaofthe

fibrousseptaandinfiltrationbypolymorphonuclearcells.

Theparenteralempiricalantibiotictherapycan be

initi-ated with imipenem,meropenem, ampicillin/sulbactam or

piperacillin/tazobactam associated with clindamycin. The

antibioticiscomplementarytodebridement.

In patients allergicto penicillin, ceftazidime,associated

withclindamycin,isanoption.12

Themortality ofnecrotizingfasciitis ranges from 6%to

76%.13_Patients_over₆₀_years_old_have_a_high_mortality_rate.

Thrombocytopenia,abnormalliverfunction,

hypoalbumine-mia, acute renal failure, and increased serum lactate are

associatedwithmortality.14

Themortalitycanreach100%innon-operatedcasesandin

thecaseofmyonecrosis.7_However,_the_mortality_rate_drops_to

12%ifthediagnosisandtreatmentaremadeinthefirstfour

daysaftertheonsetofsymptoms.15

Conclusion

Necrotizingfasciitisisasevereinfectiousdisease.Itrequires

a highindexofsuspicion toinitiateantibiotictherapy and

debridement.

Despitethediagnosisofnecrotizingfasciitisandthe

indi-cationofdebridement,blooddyscrasiasprecludedsurgeryina

timelymanner,sotherewasnoreversaloftheclinicalpicture.

Conflicts

of

interest

Theauthorsdeclarenoconflictsofinterest.

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