Abstract
Background: Necrotising fasciitis is a rare, rapidly progressing soft-tissue infection with a high mortality rate. Historically, necrotising fasciitis has been associated with penetrating injuries, and more recently with immunocompromise and severe comorbidities. This case report highlights the association of necrotising fasciitis in a child with an open distal radius fracture and a supracondylar fracture. Method and results (case report): A 10-year-old boy was admitted 24 hours after falling from a tree with a Gustilo and Anderson grade II distal radius fracture and a Gartland grade III supracondylar humerus fracture. The wound was debrided and the fractures reduced and stabilised with Kirschner wires. Within 48 hours of admission he developed a necrotising fasciitis that extended onto the chest and eventually resulted in a shoulder disarticulation. The tissue defects were covered with flaps and skin grafts and the patient was discharged home. Conclusions: This case highlights the importance of having an early and high index of suspicion for necrotising fasciitis in a child with an open contaminated fracture and delay to both antibacterial chemotherapy and surgical debridement. Tissue trauma due to open fractures may obscure the early skin signs of necrotising fasciitis as well as laboratory risk factors. In the South African context, urgent administration of cephazolin and surgical exploration must be done to prevent the devastating complication of necrotising fasciitis. Level of evidence: Level 5
Highlights
Penetrating trauma has commonly been described to precede necrotising fasciitis
Previous non-orthopaedic surgery and minor trauma has been described as the initiating event for necrotising fasciitis in children.[3,4]
A toddler with a closed Gartland I supracondylar humerus fracture had necrotising fasciitis attributed to the pressure necrosis secondary to a fibreglass cast.[6]
Summary
Penetrating trauma has commonly been described to precede necrotising fasciitis This has made the condition synonymous with war field injuries.[1] Its incidence is low in children and diagnosis remains a challenge.[2] Despite maximum care, the mortality of necrotising fasciitis is as high as 40%, attributed to the failure to recognise the disease early.[1] Previous non-orthopaedic surgery and minor trauma has been described as the initiating event for necrotising fasciitis in children.[3,4] A recent study reported four cases of necrotising fasciitis following external fixation device implantation for deformity correction or limb lengthening.[5] A toddler with a closed Gartland I supracondylar humerus fracture had necrotising fasciitis attributed to the pressure necrosis secondary to a fibreglass cast.[6] The second paediatric orthopaedic case complicated by necrotising fasciitis, had an open reduction and internal fixation for a closed ankle fracture.[7] We present a unique case of necrotising fasciitis in a child with an open fracture of the distal radius and an ipsilateral supracondylar humerus fracture (floating elbow).
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