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Salvage of Limb and Function in Necrotizing Fasciitis of the Hand: Role of Hyperbaric Oxygen Treatment and Free Muscle Flap Coverage.

ABSTRACT: We report a case of necrotizing fasciitis of the hand treated by urgent debridement followed by serial debridements, hyperbaric oxygen, and delayed free muscle flap coverage. After control of the infection, a major soft-tissue defect remained on the dorsum of the wrist and hand, exposing all extensor tendons. A rectus muscle free flap was used for wound coverage and salvage of the exposed tendons; the muscle flap was covered with a delayed skin graft. The patient regained satisfactory function with ability to extend all digits. This case emphasizes the importance of aggressive debridement and hyperbaric oxygen treatment and shows the valuable role of free muscle flap wound coverage for preservation of function in cases of necrotizing fasciitis of the hand.

Negrotizing Fasciitis of the upper extremity can be limb-threatening as well as life-threatening. Urgent and aggressive debridement is indicated to control the infection, which can expose tendons, bones, and joints. We report a case of necrotizing fasciitis of the hand treated by urgent debridement followed by serial debridements, hyperbaric oxygen (HBO), and delayed free muscle flap coverage. The patient regained satisfactory function with ability to extend all digits. This case emphasizes the importance of aggressive debridement and HBO treatment and shows the valuable role of free muscle flap for wound coverage in cases of infection. Modern therapeutic abilities extend the goals of treatment for necrotizing fasciitis to include maximal preservation of function.

CASE REPORT

A 40-year-old white woman came to the emergency department with a history of illicit drug use 3 days earlier by way of subcutaneous injection into the dorsum of the left hand, the left antecubital fossa, the right volar forearm, and both feet. On arrival, she had massive swelling of the left hand and forearm with bullae formation (Fig 1). In addition, physical examination was remarkable for localized erythema and induration over all other sites of injection. She had a fever (oral temperature, 102[degrees]F), a white blood cell count of 24.0 x 10 (9)/L. mild confusion, and tachycardia (pulse rate, 130/mm) without hypotension. Extensive air in the superficial soft tissue of the left hand and forearm was seen on radiograph. A diagnosis of necrotizing fasciitis was made, and the patient was taken urgently to the operating room for debridement of the left hand, forearm, and all other injection sites.

On exploration, there was extensive necrosis of the fascia of the left hand, wrist, and forearm with necrotic overlying skin and subcutaneous tissue (Fig 2). Also found were abscesses in the left antecubital fossa, right volar forearm, and dorsa of both feet. A repeat debridement procedure was done within 24 hours, 2 days later, and then 6 days subsequently. After the initial debridement, the patient's vital signs became stable within 24 hours. Subsequently, she received daily HBO therapy for 4 days, each for 90 minutes within a monoplace chamber at 2 ATA (atmosphere, absolute). Twice a day, wet-to-moist dressings were applied after the second debridement.

Cultures grew multiple organisms, including [beta]-, [alpha]-, and [gamma]-hemolytic streptococci, Staphylococcus species, bacteroides, and other anaerobes. The patient received intravenous triple antibiotics for broad spectrum coverage. The infection was controlled after the third debridement. In the fourth procedure, 9 days after admission, partial closure of all wounds with final debridement was done. At this point, there was exposure of all extensor tendons from the distal forearm to the level of the metacarpophalangeal joints (Fig 3). The tendons were dried and void of paratenon but lacked suppuration. To preserve extension of the digits, coverage with vascularized tissue was required. At 11 days, a rectus muscle free flap provided complete coverage of the exposed tendons (Fig 4). The muscle was covered with a split-thickness skin graft 6 days later. The patient healed uneventfully, and hand therapy was instituted for 6 months. She maintained satisfactory extension of all digits of the left hand (Figs 5 and 6).

DISCUSSION

Necrotizing fasciitis is a rapidly progressive and life-threatening infection of the soft tissue, characterized by widespread necrosis of the superficial fascia, subcutaneous fat, and deep fascia. When it involves the extremity, it can become limb-threatening. A large body of literature describes this clinical entity and its treatment. (1-3) Early and aggressive debridement and broad spectrum antibiotics are essential in treatment. Even though no randomized, controlled study has been done in humans, there is enough clinical and experimental data to support the use of HBO in necrotizing fasciitis. A summary of multiple clinical series showed a mortality rate of 43.5 %( 121/278) without HBO compared with 20.7% (57/276) with HBO therapy. (4) The rationale for using HBO includes reversal of hypoxia, enhancement of neutrophil function, and direct toxic effects on certain bacteria. (5-7)

With the current therapy of aggressive surgical debridement, effective antibiotics, and HBO, the goals of management in necrotizing fasciitis should be extended to include maximal preservation of function. When tendons become extensively exposed, but without liquefactive necrosis, they should be preserved for definitive coverage. When wound conditions and the patient's systemic recovery are maximal, vascularized tissue can be transferred to cover the exposed tendons and other vital structures. Muscle flap coverage offers revascularization of vital structures, promotes antibiotic delivery, and enhances leukocyte function. (8) However, the feasibility of free flap coverage will depend on the availability of recipient vessels.

Our patient had preservation of finger extension through this aggressive approach of wound management and coverage. She has residual stiffness in flexion at the metacarpophalangeal and proximal interphalangeal joints (Figs 5 and 6), but this limitation is expected due to the severity of the initial infection alone. This case emphasizes that modern therapeutic abilities can extend the goals of treatment for necrotizing fasciitis to include maximal preservation of function.

From the Division of Plastic Surgery, Department of Surgery, University of Arkansas for Medical Sciences, Little Rock.

Reprint requests to James C. Yuen, MD, University of Arkansas for Medical Sciences, 4301 w Markham, Slot 720, Little Rock, AR 72205.

References

(1.) Riseman JA, Zamboni WA, Curtis A, et al: Hyperbaric oxygen therapy for necrotizing fasciitis reduces mortality and the need for debridements. Surgery 1990; 108:847-850

(2.) Brown DR, Davis NL, Lepawsky M, et al: A multicenter review of the treatment of major truncal necrotizing infections with and without hyperbaric oxygen therapy. Am J Surg 1994; 167:485-489

(3.) Green RJ, Dafoe DC, Raffin TA: Necrotizing fasciitis. Chest 1996; 110:219-229

(4.) Clark LA, Moon RE: Hyperbaric oxygen in the treatment of life-threatening soft-tissue infections. Respir Care Clin North Am 1999; 5:203-219

(5.) Kindwall EP, Gottlieb LJ, Larson DL: Hyperbaric oxygen therapy in plastic surgery: a review article. Plast Reconstr Surg 1991; 88:898-908

(6.) Cohn GH: Hyperbaric oxygen therapy promoting healing in difficult cases. Postgrad Med 1986; 79:89-92

(7.) Brown RB, Sands M: Infectious disease indications for hyperbaric oxygen therapy. Compr Ther 1995; 21:663-667

(8.) Mathes SJ, Alpert BS, Chang N: Use of the muscle Hap in chronic osteomyelitis: experimental and clinical correlation. Plast Reconstr Surg 1982; 69:815-829

RELATED ARTICLE: KEY POINTS

* Necrotizing fasciitis requires urgent and aggressive debridement for limb salvage.

* Hyperbaric oxygen treatment can be beneficial as adjunctive treatment.

* Major tendon exposure can be salvaged with microvascular muscle flap transfer (free flap).

* Despite dismal clinical presentation, satisfactory outcome can be achieved with aggressive treatment in certain cases.
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Author:Feng, Zuliang
Publication:Southern Medical Journal
Geographic Code:1USA
Date:Feb 1, 2002
Words:1216
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