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A fall to remember

Copyright © 2010 Society of Hospital Medicine

A healthy 44‐year‐old man presented to the emergency room with buttock pain, 2 days after falling from a 4‐foot table onto a cement floor, striking his right buttock. On presentation he was in moderate distress, with heart rate = 130 beats per minute (bpm) and blood pressure = 80/40 mm Hg. There was a 2‐cm area of erythema on the right flank, and mild tenderness of the right buttock. There was no evidence of skin anesthesia or crepitance. Initial laboratory results were notable for creatinine = 1.5 mg/dl, creatine phosphokinase = 11,500 U/L, lactate = 6.1 mmo/L, and white blood cell count = 10 k/UL, with 93% neutrophils. Plain radiography of the hip and spine were negative for fractures and soft tissue gas. Despite receiving multiple doses of narcotic analgesia, the patient continued to complain of severe pain. Within 2 hours of presentation, the right flank erythema extended proximally up the back and distally to the right thigh (Figure 1). The patient was taken to the operating room for surgical exploration and was diagnosed with necrotizing fasciitis extending from his posterior neck to the right popliteal fossa (Figures 2 and 3). Intraoperative cultures grew Group A streptococcus, confirming a diagnosis of Type II necrotizing fasciitis. The patient required multiple debridements and subsequent reconstructive procedures. After more than 3 months in the hospital and acute rehabilitation, he returned home.

Figure 1

After 2 hours, the patient's right flank erythema extended proximally up the back and distally to the right thigh.

Figure 2

At surgical exploration, necrotizing fasciitis was diagnosed, extending from the patient's posterior neck to the right popliteal fossa.

Figure 3

At surgical exploration, necrotizing fasciitis was diagnosed, extending from the patient's posterior neck to the right popliteal fossa.

Necrotizing fasciitis is a rapidly progressive infection that spreads along fascial planes, causing necrosis of subcutaneous tissues. Type II necrotizing fasciitis is a monomicrobial infection and occurs in healthy patients, with blunt trauma being a known precipitant. The classic finding in necrotizing fasciitis is pain out of proportion to the physical examination. Additionally, patients will typically present with septic shock and end‐organ dysfunction. Diagnosis requires a strong index of suspicion and surgical exploration is necessary for diagnosis and treatment.

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