Necrotizing fasciitis

1. Necrotizing Fasciitis And
Role of Physiotherapy: A
Case Study
As the End Of Orthopaedics/Surgery Posting
By :
DR Hafiz Mukhtar Musa
1

2. Synopsis
 Introduction
 Epidemiology
 Pathophysiology
 Clinical Manifestation
 Risk Factors
 Differential Diagnosis
 Diagnosis
 Management
 Conclusion
 Recommendation
 References 2

3. Introduction :
What is Necrotizing Fasciitis?
 Necrotizing fasciitis is a life-threatening, progressive,
rapidly spreading inflammatory infection located in the
deep fascia and subcutaneous tissue, but can also extend
to involve muscles and skin
( Naqvi et al, 2009)
Also known as: “flesh-eating Disease’’.
 3 types of NF.
 Type I : A polymicrobial .
 Type II Group A Streptococcus bacteria (most common
case)
 Type III : Clostridium perfringens

3

4. Epidemiology
 Necrotizing fasciitis is a worldwide infection of public health concern with greater prevalence especially in pre-
antibiotic era. (Ozturk, et al, 2005)
 In United State of America, the NF occurs in 4.3 per 100,000 of the population. In United Kingdom 500 new
cases of necrotizing fasciitis were estimated per year. NF commonly occurs in male, and has a male to female ratio
of 3:1.(Shaikh et al, 2012)
 However no enough data to capture the prevalence of NF in Nigeria, but according to a study conducted by
Samaila and Sani 2012,(M:F=3:1)
4

5. Pathophysiology
Microbial inversion of the subcutaneous tissues through external trauma or direct spread from a perforated viscus
Bacterial growth within the superficial fascia releases a mixture of enzymes and endo/exotoxins
Results in poor microcirculation and ischeamia in the affected tissues
Cell death thereby causing Necrosis of the affected tissues
5

6. Clinical Features
 This is divided into three (3) into 3 Stages
(i) Early onset symptoms
(ii) Advanced symptoms
(iii) Critical symptoms
(Kumar et al,2009)
6

7. What are the early symptoms and signs of NF?
 Flu like symptoms that include fever, chills, nausea, weakness,
dizziness, aches and a heart rate of more than 100 beats per
minute.
 Skin becomes tender, warm, red in color, and will start to
swell.
 Patients may experience pain greater than expected from the
appearance of the wound.
 Subcutaneous tissue may also have a hard feel on palpation.
7

8. Advanced symptoms…
 The area of the body experiencing pain begins
to swell excessively.
 Multiple discolored patches develop to produce
a large area of gangrenous skin.
 The normal skin and subcutaneous tissue are
loosened.
 Large, dark marks that become blisters filled
with a yellow-green necrotic fluid appear.
8

9. Critical symptoms…
 The critical symptoms are:
 30% of patient’s develop hemorrhagic bullae which may
cause them to become anemic.
 Vasculature of the skin becomes inflamed and
thrombosed. Resulting in necrotic eschars that look like
deep thermal burns.
 Without treatment, secondary involvement of deeper
muscle layers may occur.
 Patients may become numb because of nerve damage .
9

10. Cofactors that Increase risks
 Immuno-suppression i.e Diabetes
 NSAIDS
 Severe illnesses: Liver disease
 Poor Hygeine (Singh et al,2012)
10

11. Differential Diagnosis
 Cellulitis
 Myositis
 Impetigo
 (Stevens and Chambers HF 2014)
11

12. Investigation
 Some of these tests include:
1. Blood Test: CBC
2. Testing for elevated or lowered creatinine, glucose,bicarbonate,hemglobin, and WBC
levels.
3. X-ray
4. And most importantly antibiotic culture and sensitivity tests
5.Finger Test and Biopsy
(Mayo clinic.com)12

13. 13

14. LRINF
14

15. Management of NF
 Medical Management
 Physiotherapy management
 Surgical Management
15

16. Medical Treatment of NF
 Early diagnosis and treatment is vital
 IV antibiotic treatment
 Hyperbaric oxygen therapy is recommended for anaerobic organisms
 If sepsis has set in, vasoconstricting medications should be given.
 Education and counseling
16

17. Physiotherapy management of Nf
INDICATIONS FOR PHYSIOTHERAPY MANAGEMENT
 Wound Care
 Prevention of contractures
 Decrease or Maintain Range of motion
 Loss of Muscle Strength
MANAGEMENT
ROM exercises
Transfer training
Gait training
Strengthening exercises
17

18. Surgical Management
 Wound debridement
 Skin Grafts
 Amputation
18

19. Case Study
 Informant: Patient Gender: Male
 Address:Gwarzo LGA kano Age: 50 years old
 C/C: Pain while moving Right Hand and multiple ulcer at right wrist 15 Days Ago
 Hx: He was apparently well until 15 days ago when he accidently hit his right hand to the window and sustained an abrasion
to his hand.The hand swollen up and Later developed erythema, severely painful, with mild to moderate skin rash. The rash
started from his wrist and spread to include skin of forearm, and extend distally to the medial border of Rt elbow joint, 5
days post onset of the symptoms ulcer start developing at the hand which progressively increase in size with associated
difficulty while moving the Rt Elbow joint.Upon that he tried Herbal medicine for about 2 weeks before seeking medical
attention at Gwarzo general hospital , emergency care was given and the wound was dress on daily basis for about a week in
Gwarzo General Hospital. They later reffered him to AKTH via emergency for further management .Consult was then sent to
physiotherapy for review and expert management
 PMHx: DM-, HTN-, FEVER+, TRAUMA +,PREVIOUS SKIN INFECTION-
 DrugHx: PCM,TT inj, Clindamycin
 FsHx:50years old bussiness man married with 10 children 6 male and 4 female, not taking ciggrate nor alcohol neither
Kolanut
19

20.  O/E Pt met in supine lying position with Rt Upper Limb wrapped with bandage, febrile to touch, acynosed,anectric and not in any
obvious RD
 CNS: Alert, conscious and oriented in TPP
 CVS: BP:120/80mmhg
PR:102Bpm
RR:24Cpm
Temp:37.7℃
MSS EXAM
Head and Neck: NAD
Thorax and Abdomen: NAD
Chest: Clinically clear
Back: NAD
20

21. Rt/UL :
On Inspection: Scars and open wound are present at the wrist and elbow respectively
On Palpation: Tenderness is present dorsum of the wrist
GMP:2/5
ROM:
Shoulder: full and pain free
Elbow-Flexion: 90
Extension:0
Wrist: Full and pain free
21

22.  Rt/UL
 Contracture: Absent
 Spasticity: Absent
 Tone: Normotonia
 Stiffness: Absent
 Sensation: Intact
 NPRS: 8/10
Lt/UL:NAD
L/L: NAD
Functional Abilities/disabilities
Pt cannot hold object with Rt Hand
Pt experience pain while moving the Hand
22

23. INVESTIGATIONS
23

24.  Test Score
 WBC:24mmol/L 1
 Creainine:104mg/dl 2
 Na: 129mmol/L 2
 Fever :37.6℃ 1
 Tachycardia:102BPM 1
 Total: 7/15
24

25. 25

26. Investigations…
 Finger Test:positive
 Biopsy Result :Streptococcal infecion
 X Ray: NA
26

27. Diagnosis: Necrotizing fasciitis
(associated with impaired function of Rt UL)
Treatment
Auto-assissted exercises to the U/L 20 reps TDS
Soft Tissue manipulation
Isometric exercises
Wound care education
W/P
After 8 sessions of Rx
GMP:4/5
ROM
E.flex:110
.:Pt was then discharge due to financial constraint
27

28. Conclusion
Early Physical therapy intervention facilitate wound healing, improve mobility and
independence in the patient with Necrotizing fasciitis, therefore they remain expertise to be
involve in the management of NF
Recommendation
Early referral to physiotherapy is paramount as it enhance the better outcome of the treatment
Further research should be carried out to evaluate the prevalence of NF in Nigeria
28

29. References
 SA Malik, W jan, GA Naqvi et al .Scandinavian Journal of Trauma, Resuscitation and Emergency
Medicine 2009 17:28
 Misiakos EP, Bagias G, Patapis P, Sotiropoulos D, Kanavidis P, Machairas A. Current concepts in the
management of necrotizing fasciitis. Front Surg. 20141:36.
 Abdullahi Samaila and Musa Sani Kaware , ujmr volume 2, 2017
 Fazeli M, Keramati MR. Necrotising fasciitis an epidemiological study of 102 cases. Indian J Surg.
2007;69:136-9.
 Young MH, Aronoff DM, Engleberg NC. Necrotising Fasciitis: Pathogenesis and treatment. Expert Rev
Anti Infect Ther 2005;3:279–94. 29

30.  Riseman JA, Zamboni WA, Curtis A, Graham DR, Konrad HR, Ross DS. Hyperbaric oxygen
therapy for Necrotizing fasciitis reduces mortality and the need for debridement. Surgery
1990;108:847–50.
 Hoeffel JC, Hoeffel F. Necrotising fasciitis and purpura fulminants. Plast Recon Surg.
2002;109:2165
 Young MH, Aronoff DM, Engleberg NC. Necrotising Fasciitis: Pathogenesis and treatment.
Expert Rev Anti Infect Ther 2005;3:279–94.
 Sehgal VN, Sehgal N, Sehgal R, Khandpur. Necrotizing fasciitis. J Dermatol Treat
2006;17:184–6.
30

31. THANK YOU!!!
31