Orthopedists should suspect necrotizing fasciitis in patients with out of proportion pain

Published on September 17, 2012 at 12:37 PM · No Comments

Dr. Russell Russo, an Orthopedic Surgeon at LSU Health Sciences Center New Orleans, and other researchers stress that orthopedists should have a high index of suspicion for necrotizing fasciitis, or flesh-eating bacterial infection, in every patient with pain or other symptoms that are out of proportion to the initial diagnosis. Their recommendations are published in the September 2012 issue of Orthopedics Today.

Although relatively rare and difficult to diagnose because its symptoms often resemble other conditions like synovitis or cellutitis, a missed diagnosis could lead to amputation or death.

"The infection can rapidly spread at a rate of 1 cm per hour," notes Dr. Russo. "People who have their surgery and debridement within 10 to 24 hours once they hit the door, do much better than the patients for whom the diagnosis is not made for days."

Dr. Russo says a hands-on physical examination is necessary to recognize the condition early because X-rays, CT scans and other imaging tests may not detect the disease and are time-consuming.

"Pain out of proportion to physical findings, nausea, fever, hypotension, mental confusion, loss of sensation, skin discoloration, crepitus or necrosis all signal necrotizing fasciitis," Dr. Russo emphasizes.

Many types of bacteria can cause necrotizing fasciitis, including Group A Streptococcus pyogenes and Group B Streptococcus infections. Clostridium and methicillin-resistant Staphylococcus aureus can also cause the infection. In some cases, patients can have more than one type of bacteria.

Awareness of predisposing risk factors may also aid a faster diagnosis. These include a history of trauma, obesity, rheumatoid arthritis, diabetes, kidney disease, HIV, hepatitis C, and other diseases that compromise the immune system. However, 50% of necrotizing fasciitis cases occur in healthy people, and can result from cuts, insect bites, or blunt trauma. It has been reported in healthy kids who got hit playing football and suddenly contracted necrotizing fasciitis.

"About 45% of patients do not recall obvious injuries, such as cuts, scrapes, injections or bruises that may have led to infections," says Dr. Russo. "If you have a red, warm arm, address it, and do not wait."

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