Necrotizing fasciitis physical examination: Difference between revisions

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Latest revision as of 22:56, 29 July 2020

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Yamuna Kondapally, M.B.B.S [2]

Overview

Physical examination of patients with necrotizing fasciitis is usually remarkable for local soft tissue signs such as warmth, tenderness beyond margins of erythema, swelling, erythema with ill defined margins, blistering/bullae, skin discoloration, foul discharge (greyish or brown discharge), fluctuance, crepitus, skin sloughing or necrosis, absence of lymphangitis or lymphadenopathy (lymphangitis is rarely observed in necrotizing fasciitis patients), sensory and motor deficits (e.g. localized anesthesia).^[1]^[2] Finger probe test is useful in the diagnosis of necrotizing fasciitis.^[2]

Physical Examination

Common physical examination findings associated with necrotizing fasciitis may include:^[1]^[2]

Appearance of the patient

Patients with necrotizing fasciitis appear fatigued during early stages and may have altered mental status during late stages. In end stage necrotizing fasciitis, patients exhibit signs of septic shock.

Vital signs

Skin

Jaundice
Evidence of trauma, surgery, insect or human bites, or injection sites

Local examination

Induration
Warmth
Tenderness beyond margins of erythema
Swelling
Erythema with ill defined margins
Blistering/bullae
Skin discoloration
Foul discharge (greyish or brown discharge)
Fluctuance
Crepitus
Skin sloughing or necrosis
Absence of lymphangitis or lymphadenopathy (lymphangitis is rarely observed in necrotizing fasciitis)
Sensory and motor deficits (e.g. localized anesthesia)

Stage (Early)	Signs
Early	● Tenderness to palpation (extending beyond the apparent area of skin involvement) ● Erythema ● Swelling ● Warm to palpation
Intermediate	● Blister or bullae formation (serous fluid) ● Skin fluctuance ● Skin induration
Late	● Hemorrhagic bullae ● Skin anesthesia ● Crepitus ● Skin necrosis with dusky discoloration progressing to frank gangrene

Finger Probe Test

Finger probe test is useful in the diagnosis of necrotizing fasciitis.^[2]

Procedure

This test is carried out in the ward, emergency room and in the theatre under local or general anesthesia.
After infiltrating the area, a 2cm incision is made down to the deep fascia.
Fascia will be swollen and grey on gross inspection.
Gentle probing with index finger is performed at the level of deep fascia and if the tissue dissects with the minimal resistance, then finger probe test is considered positive.
Signs suggesting necrotizing fasciitis include:
- Lack of bleeding
- Lack of normal tissue resistance on finger probe
- Oozing of malodorous "dish water fluid"

References

↑ ^1.0 ^1.1 Young MH, Aronoff DM, Engleberg NC (2005). "Necrotizing fasciitis: pathogenesis and treatment". Expert Rev Anti Infect Ther. 3 (2): 279–94. doi:10.1586/14787210.3.2.279. PMID 15918785.
↑ ^2.0 ^2.1 ^2.2 ^2.3 Puvanendran R, Huey JC, Pasupathy S (2009). "Necrotizing fasciitis". Can Fam Physician. 55 (10): 981–7. PMC 2762295. PMID 19826154.

[pmid15918785-1] 1.0 ^1.1 Young MH, Aronoff DM, Engleberg NC (2005). "Necrotizing fasciitis: pathogenesis and treatment". Expert Rev Anti Infect Ther. 3 (2): 279–94. doi:10.1586/14787210.3.2.279. PMID 15918785.

[pmid19826154-2] 2.0 ^2.1 ^2.2 ^2.3 Puvanendran R, Huey JC, Pasupathy S (2009). "Necrotizing fasciitis". Can Fam Physician. 55 (10): 981–7. PMC 2762295. PMID 19826154.

[1]

[2]

@@ Line 4: / Line 4: @@
 ==Overview==
+Physical examination of patients with necrotizing fasciitis is usually remarkable for local soft tissue signs such as warmth, tenderness beyond margins of [[erythema]], swelling, [[erythema]] with ill defined margins, [[blister|blistering]]/bullae, skin discoloration, foul discharge (greyish or brown discharge), fluctuance, [[crepitus]], skin sloughing or [[necrosis]], absence of [[lymphangitis]] or [[lymphadenopathy]] ([[lymphangitis]] is rarely observed in necrotizing fasciitis patients), sensory and motor deficits (e.g. [[anesthesia|localized anesthesia]]).<ref name="pmid15918785">{{cite journal| author=Young MH, Aronoff DM, Engleberg NC| title=Necrotizing fasciitis: pathogenesis and treatment. | journal=Expert Rev Anti Infect Ther | year= 2005 | volume= 3 | issue= 2 | pages= 279-94 | pmid=15918785 | doi=10.1586/14787210.3.2.279 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=15918785  }} </ref><ref name="pmid19826154">{{cite journal| author=Puvanendran R, Huey JC, Pasupathy S| title=Necrotizing fasciitis. | journal=Can Fam Physician | year= 2009 | volume= 55 | issue= 10 | pages= 981-7 | pmid=19826154 | doi= | pmc=2762295 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19826154  }} </ref> Finger probe test is useful in the diagnosis of necrotizing fasciitis.<ref name="pmid19826154">{{cite journal| author=Puvanendran R, Huey JC, Pasupathy S| title=Necrotizing fasciitis. | journal=Can Fam Physician | year= 2009 | volume= 55 | issue= 10 | pages= 981-7 | pmid=19826154 | doi= | pmc=2762295 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19826154  }} </ref>
 ==Physical Examination==
-Common physical examination findings associated with necrotizing fasciitis may include:
+Common physical examination findings associated with necrotizing fasciitis may include:<ref name="pmid15918785">{{cite journal| author=Young MH, Aronoff DM, Engleberg NC| title=Necrotizing fasciitis: pathogenesis and treatment. | journal=Expert Rev Anti Infect Ther | year= 2005 | volume= 3 | issue= 2 | pages= 279-94 | pmid=15918785 | doi=10.1586/14787210.3.2.279 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=15918785  }} </ref><ref name="pmid19826154">{{cite journal| author=Puvanendran R, Huey JC, Pasupathy S| title=Necrotizing fasciitis. | journal=Can Fam Physician | year= 2009 | volume= 55 | issue= 10 | pages= 981-7 | pmid=19826154 | doi= | pmc=2762295 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19826154  }} </ref>
-'''Appearance of the patient'''
+===Appearance of the patient===
-Patients with necrotizing fasciitis appear fatigued during early stages and may have altered mental status during late stages. In end stage necrotizing fasciitis, patients exhibit signs of septic shock.
+*Patients with necrotizing fasciitis appear [[fatigue|fatigued]] during early stages and may have [[altered mental status]] during late stages. In end stage necrotizing fasciitis, patients exhibit signs of [[septic shock]].
-'''Vital signs'''
+===Vital signs===
-*Fever (is often absent)
+*[[Fever]] (may be absent)
-*Tachycardia
+*[[Tachycardia]]
-*Low blood pressure
+*[[Low blood pressure]]
-*Tachypnea
+*[[Tachypnea]]
-'''Skin'''
+===Skin===
+*[[Jaundice]]
+*Evidence of [[trauma]], surgery, insect or human bites, or injection sites
-*Jaundice
+===Local examination===
-*Evidence of trauma, surgery, insect or human bites, or injection sites
-'''Local examination'''
+*[[Induration]]
-*Induration
 *Warmth
-*Tenderness beyond margins of erythema
+*Tenderness beyond margins of [[erythema]]
-*Swelling
+*[[Swelling]]
-*Erythema with ill defined margins
+*[[Erythema]] with ill defined margins
-*Blistering/bullae
+*[[Blister|Blistering]]/bullae
 *Skin discoloration
 *Foul discharge (greyish or brown discharge)
 *Fluctuance
-*Crepitus
+*[[Crepitus]]
-*Skin sloughing or necrosis
+*Skin sloughing or [[necrosis]]
-*Absence of lymphangiitis or lymphadenopathy
+*Absence of [[lymphangitis]] or [[lymphadenopathy]] ([[lymphangitis]] is rarely observed in necrotizing fasciitis)
-*Sensory and motor deficits (e.g. localized anesthesia)
+*Sensory and motor deficits (e.g. [[anesthesia|localized anesthesia]])
-{| class="wikitable" align="center"
+{| class="wikitable" style="text-align:left"
 |-
-! Stage 1 <br>
+! Stage
 (Early)
-! Stage 2 <br>
+! Signs
-(Intermediate)
+|-
+| Early
-! Stage 3
+| ● [[Tenderness]] to [[palpation]] (extending beyond the apparent area of skin involvement) <br> ● [[Erythema]] <br> ● Swelling <br> ● Warm to palpation
-(Late)
 |-
-| Tenderness to
+| Intermediate
-palpation (extending
-beyond the apparent
+| ● [[Blister]] or bullae formation ([[serous fluid]]) <br> ● Skin fluctuance <br> ● Skin [[induration]]
-area of skin
-involvement)
+|-
-Erythema
-Swelling
-Warm to palpation
-| Blister or bullae
+| Late
-formation
-(serous fluid)
-Skin fluctuance
-Skin induration
-| Hemorrhagic bullae
+| ● Hemorrhagic bullae <br> ● [[Anesthesia|Skin anesthesia]] <br> ● [[Crepitus]] <br> ● Skin [[necrosis]] with dusky discoloration progressing to frank [[gangrene]]
-Skin anesthesia
-Crepitus
-Skin necrosis with
-dusky discoloration
-progressing to frank
-gangrene
 |-
 |}
+===Finger Probe Test===
+*Finger probe test is useful in the diagnosis of necrotizing fasciitis.<ref name="pmid19826154">{{cite journal| author=Puvanendran R, Huey JC, Pasupathy S| title=Necrotizing fasciitis. | journal=Can Fam Physician | year= 2009 | volume= 55 | issue= 10 | pages= 981-7 | pmid=19826154 | doi= | pmc=2762295 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19826154  }} </ref>
+====Procedure====
+:*This test is carried out in the ward, emergency room and in the theatre under [[Anesthesia|local]] or [[general anesthesia]].
+:*After infiltrating the area, a 2cm incision is made down to the [[fascia|deep fascia]].
+:*Fascia will be swollen and grey on gross inspection.
+:*Gentle probing with index finger is performed at the level of deep fascia and if the tissue dissects with the minimal resistance, then finger probe test is considered positive.
+:*Signs suggesting necrotizing fasciitis include:
+:**Lack of [[bleeding]]
+:**Lack of normal tissue resistance on finger probe
+:**Oozing of malodorous "dish water fluid"
 ==References==
 {{Reflist|2}}
+[[Category:Emergency mdicine]]
 [[Category:Disease]]
-[[Category:Dermatology]]
+[[Category:Up-To-Date]]
 [[Category:Infectious disease]]
+[[Category:Surgery]]
+[[Category:Orthopedics]]