Gas gangrene in orthopaedic patients

Clostridial Catastrophe in Orthopedics - A Case Report

Introduction

We present a case of a 51-year-old gentleman admitted to the emergency department with a 2-day history of severe left forearm symptoms following a Gustillo-Anderson type II left both bone fracture sustained during a bicycle accident. Initially managed conservatively at an outside facility with an above-elbow backslab, his condition rapidly deteriorated, necessitating transfer to our institution. Adding complexity to his clinical presentation was his history of poorly controlled type 2 diabetes mellitus.

Case Report

On arrival, the patient exhibited fever and pronounced limb abnormalities, including extensive swelling, brownish skin with oozing blisters, and subcutaneous crepitus spanning from wrist to elbow. Radiological imaging unequivocally identified gas within the forearm compartments, signifying a severe infection. A provisional diagnosis of gas gangrene was made, later confirmed by culture report through intraoperative sampling.

Conclusion

Gas gangrene was definitively diagnosed, prompting immediate emergency surgery. Extensive necrosis was discovered during the procedure, necessitating an above-elbow amputation for limb salvage. Unfortunately, postoperatively, the infection continued to advance, extending to the chest and neck regions. Expert consultations in cardiothoracic and general surgery led to further extensive surgical interventions, including complete glenohumeral disarticulation and fasciotomy over chest for surgical emphysema. Microbiological analysis identified Clostridium perfringens, Escherichia coli, and Enterococcus as causative organisms. Aggressive antibiotic therapy, repeated surgical debridement, and meticulous wound management ultimately resulted in a successful recovery. The patient was discharged 20 days after initial presentation, underscoring the critical importance of prompt recognition and multidisciplinary management in severe gas gangrene cases, particularly in patients with underlying medical comorbidities.

Polymicrobial infection presenting as non-clostridial gas gangrene in a non-diabetic trauma patient. A case report and review of literature

BACKGROUND

Clostridium species are known to be the primary causative organism of gas gangrene. Non-clostridial gas gangrene (NCGG) is another rare necrotizing entity often associated with an underlying disease, particularly diabetes mellitus, and has a high mortality rate.

CASE REPORT

A 16-year-old, immunocompetent male was referred to us after four days, following a roadside accident, with a degloving injury over the thigh and knee along with fractures around the knee. Although clinico-radiologically suspicious of gas gangrene, the initial smear report was negative for any Gram-positive bacilli. On the same day, he underwent aggressive debridement with an external fixator spanning the knee to salvage the limb. On post-operative day one, due to deteriorating general clinical condition and a strong clinical suspicion of gas gangrene, he underwent above-knee amputation (open stump) after discussion with microbiologists and physicians.

RESULTS

Polymicrobial non-clostridial infection was seen in culture reports taken serially at different stages of management. The latest follow-up showed a healed amputation stump following split skin grafting.

CONCLUSION

Although rare, polymicrobial infections can present as non-clostridial gas gangrene even in an immunocompetent patient. A high index of clinical suspicion with a multi-disciplinary approach helps in early decision-making to avoid a devastating outcome.

Frightening" Resistant Clostridial Myonecrosis: A Case Report

Clostridial myonecrosis is a diffuse necrotizing infection of deep soft tissues. It is known for its acute, rapid progression, poor prognosis, and high mortality. We report a case of traumatic clostridial myonecrosis, a 17-year-old, previously healthy female reported to our department with the complaint of pain in her left arm a week after she suffered a fall from her chair on to her left arm. Due to the injury sustained in the incident, under suspicion of a forearm fracture, a cast was applied to her left arm at a local polyclinic. However, after a few days, she reported unbearable pain, which led to the removal of the cast, and that is when diffuse crepitations due to gaseous accumulation were noted in her entire left upper limb. A week later, X-ray studies failed to reveal any fracture or abnormality. The patient was started on broadspectrum antibiotic coverage with intravenous (IV) benzylpenicillin, rifampicin, and clindamycin for a considerable period of time, but there was no improvement in her condition and the infection continued to spread into adjacent soft tissues, requiring intervention with hyperbaric oxygen therapy.

Gas gangrene following implant removal after the union of a tibial plateau fracture: a case report

Background

Gas gangrene is an invasive, fatal anaerobic infection that is characterized by acute, rapid evolution and high mortality. Gas gangrene is often secondary to open fractures with deep wounds but is extremely rare in the patients undergoing elective surgery. Implant removal is a common elective operation in orthopedics after the union of fractures, and the complications of this surgery include infection, nerve injury and re-fracture. However, to the knowledge of the authors, there is no report in the literature on gas gangrene following implant removal. Here, we present a case study of gas gangrene following the removal of an internal fixation device after the union of a tibial plateau fracture.

Case presentation

A 59-year-old man with a postoperative union of a left tibial plateau fracture after open reduction and internal fixation complained of severe pain in the wound region on the first morning after implant removal surgery, and the incision was severely swollen and filled with hemorrhagic content. On the second morning, the patient’s symptoms were aggravated progressively. The patient experienced delirium on the third morning after surgery, and a physical examination revealed subcutaneous crepitus extending along the length of the limb, and roentgenograms revealed the accumulation of gas in soft tissue. Gas gangrene was highly suspected, and the left femoral amputation was performed the following night at approximately 11 p.m. General supportive therapy and antibiotic therapy were given subsequently, and the patient was recovered and discharged after his vital signs were stable.

Conclusions

Although gas gangrene is rare, its high mortality and disability indicate that we should pay attention to its prophylaxis, and strict aseptic techniques should be emphasized for even the most minor procedure.

Autoamputation of diabetic toe with dry gangrene: a myth or a fact?

Diabetes is associated with various complications and reduced quality of life. Of the many complications, some are life-threatening. Among these, foot complications remain an important concern. The major foot complications include foot ulceration, cellulitis, abscess, wet gangrene, dry gangrene, and necrotizing fasciitis, with different pathophysiological concepts behind each of them. Gangrene occurs due to reduced blood supply in the body tissues that leads to necrosis. This condition may arise because of an injury, infection, or other health conditions, majorly diabetes. Gangrene is classified as dry, wet, and gas gangrene. In case of wet and gas gangrene, surgical amputation is usually performed to prevent the spread of infection to other tissues. In dry gangrene, due to the presence of clear demarcation, autoamputation is preferred in certain parts of the globe. The present review aims to analyze the mode of dry gangrene management in diabetic patients based on previous evidence and plans to highlight various management strategies available for dry gangrene and the advantages/disadvantages of different treatments with special consideration to autoamputation.