This patient has evidence of necrotizing fasciitis on ultrasound. He had plain films taken which illustrated gas in the tissues.
He was taken to the OR for debridement of the area and was noted to have purulent debris in both the volar and dorsal forearm compartments with resultant compartment syndrome. He had fasciotomies of both compartments and the excision of the purulent material. He subsequently underwent multiple debridements and eventually had a right shoulder disarticulation due to purulent material found throughout his forearm, elbow and biceps. His wound cultures grew out klebsiella and VRE.
Necrotizing Fasciitis
Necrotizing fasciitis (NF) is a rapidly spreading, progressive infection of the deep fascia with secondary necrosis of the subcutaneous tissues. Subcutaneous air is classically associated with NF due to gas forming organisms.
Cheng et al, noted that upper extremity NF has a higher mortality rate (35%). Mental status depression and respiratory distress on presentation were factors associated with higher mortality. Diabetes and other immunocompromised states are also risk factors.
On Ultrasound, NF appears to distort the facial layer, causing thickening of the subcutaneous tissue and muscle layer with hypoechoic fluid collections adjacent. Gas may also be visualized as a hyperechoic area with posterior shadowing (the hyperechoic area appears to fade into the shadow).