NF tends to begin with constitutional symptoms of fever and chills. After 2–3 days, erythema is noted, and supralesional vesiculation or bullae formation ensues. Serosanguineous fluid may drain from the affected area. Necrotizing fasciitis may develop after skin biopsy; at needle puncture sites in those using illicit drugs; and after episodes of frostbite, chronic venous leg ulcers, open bone fractures, insect bites, surgical wounds, and skin abscesses. However, in many cases, no association with such factors can be made. NF may also occur in the setting of diabetes mellitus, surgery, trauma, or infectious processes.

Findings in NF may include all or some of the following clinical signs. A rapidly advancing erythema with painless ulcers appearing as the infection spreads along the fascial planes. A black necrotic eschar may be evident at the borders of the affected areas. Metastatic cutaneous plaques may occur. Septicemia is typical and leads to severe systemic toxicity and rapid death unless appropriately treated. In individuals with diabetes, crepitus is often evident, as are nonclostridial anaerobic infections. Purpura with or without bullae formation, occasionally with a lack of cutaneous erythema and heat, may be found, which does not preclude the diagnosis of NF.

Although the following features can occur with cellulitis, they are suggestive of NF:

Laboratory tests, along with appropriate imaging studies, may facilitate the diagnosis of necrotizing fasciitis. Although the laboratory parameters may vary in a given clinical setting, the following may be associated with necrotizing fasciitis:

Standard radiographs are of little value unless free air is depicted, as with gas-forming infections. MRI or CT scan delineation of the extent of NF may be useful in directing rapid surgical debridement

Excisional deep skin biopsy may be helpful in diagnosing and identifying the causative organisms. Cultures of the affected tissue obtained at initial debridement may be helpful. Gram staining of the exudate may provide a clue as to whether a type I or type II infection is present; the type influences the antibiotic therapy

This is a life threatening condition with a very high mortality rate. Management should occur within a multidisciplinary team setting. Ideally, the patient should be managed in an intensive care unit where hemodynamic parameters can be closely monitored. They will require;

Once the diagnosis of NF is made, immediate surgical debridement is necessary. Surgical debridement and evaluations should be repeated almost on a daily basis until further tissue necrosis stops and the growth of fresh viable tissue is observed. If a limb or organ is involved, amputation may be necessary because of irreversible necrosis and gangrene or because of overwhelming toxicity.

These resultant wounds are best managed using a negative pressure dressing and once the tissue necrosis has stopped and the wounds are granulating they can be covered with a split skin graft.

A 23 year old right hand dominant carpenter presented to the emergency department with a swollen and painful right index finger following a laceration with a Stanley knife 7 days earlier. He presented with a painful, swollen and stiff finger (Fig. 9.2) which had been gradually worsening.

If PFT is suspected, it is important to keep the patient nil by mouth and urgently refer them to a Plastic Surgery Unit. The indication for surgical drainage includes history and physical examination consistent with acute or chronic flexor tenosynovitis. In certain circumstances when acute flexor tenosynovitis presents within the first 24 h of onset, medical management may initially be trialed. Prompt improvement of symptoms and physical findings must follow within the ensuing 12 h; otherwise, surgical intervention is necessary.