Necrotizing Soft-Tissue Infections: An Orthopaedic Emergency

Adam Lee, MD; Addison May, MD, FACS, FCCM; William T. Obremskey, MD, MPH


J Am Acad Orthop Surg. 2019;27(5):e199-e206. 

In This Article

Abstract and Introduction


Necrotizing soft-tissue infections are caused by a variety of bacterial pathogens that may affect patients at any age or health status. This orthopaedic emergency initially presents with nonspecific signs such as erythema and edema. As the disease progresses, classic signs such as bullae, cutaneous anesthesia, ecchymosis, tense edema, and gas can be seen. A high level of suspicion is needed to properly identify and treat in a timely manner. Pain out of proportion to presentation and rapid progression even with appropriate antibiotic treatment should heighten suspicion of a necrotizing soft-tissue infection. The mainstay of management is extensive débridement and decompression of all necrotic tissue and broad-spectrum antibiotics. Débridements are repeated to ensure that disease progression has been halted. Early surgical débridements should take precedent over transfer because of the high rate of limb loss and mortality as a result of surgical delay.


Hippocrates astutely described what we now know as necrotizing soft-tissue infection (NSTI). He called it a "malignant case of erysipelas" where "fatal cases were many." He noted a precipitating event as a "trivial accident or very small wound" that progressed to "abscessions ending in suppurations" or where "flesh, sinews and bones fell away in large quantities." In addition, the hallmark dishwater purulence was described as "flux … not like pus but … a different sort of putrefaction with a copious and varied flux." He saw that in cases that did not have discrete abscess formation with frank drainage "there were many deaths."[1] This account describes the common presentation, progression, and natural history of untreated NSTIs. For reasons that are not agreed on, this disease process has a high morbidity and mortality despite medical advances and necessitates that surgeons have a high degree of suspicion to diagnose and make a decisive move to treat once a diagnosis of NSTI is confirmed or highly suspected.

NSTIs are not uniform in presentation or extent of involvement. NSTIs include any or all soft-tissue layers (ie, skin, subcutaneous fat, fascia, muscle). Necrotizing fasciitis, a subset of this broad disease entity, is the most common manifestation of NSTI; however, one must be aware of other presentations as well (ie, necrotizing adipositis, pyomyositis). The general diagnosis and management principles for necrotizing fasciitis and other specific forms hold true for all NSTIs and therefore will be discussed broadly in the context of this review.

Unfortunately, NSTIs fall on a spectrum of clinical severity. Unlike nonnecrotizing soft-tissue infections, NSTIs cannot be managed with antibiotics alone because these infections commonly occur in the extremities. Orthopaedic surgeons are often involved in the early management of this pathology as consultants and therefore have a critical role in raising the possibility of and potentially diagnosing NSTI.[2] In its most virulent form, an NSTI can be rapidly progressive and quickly fatal without intervention. Awareness is crucial in preventing this outcome, and a current review of the relevant literature is presented to raise awareness.