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Thread: Extremity Conditions - CELLULITIS

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    Arrow Extremity Conditions - Associated Clinical Features

    Extremity Conditions - CELLULITIS


    Associated Clinical Features

    Cellulitis is infection of the skin or subcutaneous tissues from local invasion, traumatic wounds, or hematogenous dissemination. The local inflammatory response is characterized by erythema with poorly defined borders, edema, warmth, pain, and limitation of movement. Fever and constitutional symptoms may be present and are commonly associated with bacteremia. Trauma, lymphatic or venous stasis, immunodeficiency, and foreign bodies are predisposing factors.

    There may be enlarged regional lymph nodes. Organisms commonly causing cellulitis are group A beta hemolytic Streptococcus and Staphylococcus aureus in nonintertriginous skin not associated with an ulcer, gram-negative organisms in intertriginous skin and ulcerations, and Haemophilus influenzae in children younger than 3 years. In immunocompromised hosts, Escherichia coli, Klebsiella species, Enterobacter species, and Pseudomonas aeruginosa may be the etiologic agents.
    Differential Diagnosis

    Deep venous thrombosis of the lower extremities, erythema nodosum, septic or inflammatory arthritis, osteomyelitis, herpes zoster, allergic reactions, arthropod envenomation, and burns are included in the differential diagnosis of cellulitis.
    Emergency Department Treatment and Disposition

    Treatment of minor cases commonly consists of immobilization, elevation, analgesia, and oral antibiotics with reevaluation in 48 h. Admission and parenteral administration of antibiotics may be necessary for immunocompromised or toxic-appearing patients or those who do not initially respond to outpatient therapy.
    Clinical Pearls
    1. Aggressive treatment of cellulitis with broad-spectrum parenteral antibiotics in immunocompromised patients (e.g., diabetes mellitus) is warranted.
    2. Fever is uncommon and often associated with bacteremia.
    3. Radiography for the presence of foreign body or gas in the tissue should be considered.
    4. Leading-edge aspirates are of low yield but may be of help in a toxic-appearing patient.
    5. The incidence of Haemophilus influenzae cellulitis in children has decreased significantly with HIB vaccination.

    Associated Clinical Features

    felon is a pyogenic infection of the distal pulp space often caused by staphylococci or streptococci. A felon cannot decompress itself because the collection of pus is trapped between septa that attach the skin to the distal phalanx. This condition is characterized by severe pain, exquisite tenderness, and tense swelling of the distal pulp with erythema (Fig. 12.2). There may be a visible collection of pus or palpable fluctuance. Complications include deep ischemic necrosis, osteomyelitis, septic arthritis, and septic tenosynovitis.


    Associated Clinical Features
    Gangrene denotes tissue that has lost its blood supply and is undergoing necrosis. The term dry gangrene (Figs. 12.3, 12.4) is used for tissues undergoing sterile ischemic coagulative necrosis, whereas wet gangrene is associated with bacteria proteolytic decomposition. Streptococcus pyogenes is often implicated in rapidly developing (6 h to 2 days) gangrene in traumatic and surgical wounds. Clostridia, anaerobic streptococci, and mixed aerobic and anaerobic flora can also be seen in wounds caused by trauma, surgery, or diabetic ulcers.
    Necrotizing Fasciitis

    Associated Clinical Features

    This uncommon, severe infection involves the subcutaneous soft tissues, including the superficial and deep fascial layers, with early sparing of the skin and late involvement of the muscle. It is most commonly seen in the lower extremities, abdominal wall, perianal and groin area, and postoperative wounds but can manifest in any body part. The infection is spread most commonly from a site of trauma or surgical wound, abscess, decubitus ulcer, or intestinal perforation. Alcohol, parenteral drug abuse, and diabetes mellitus are predisposing factors. Omphalitis may progress to necrotizing fasciitis in the newborn. Pain, tenderness, erythema, swelling, warmth, shiny skin, lymphangitis, and lymphadenitis are early clinical findings. Later, there is rapid progression with changes in skin color, formation of bullae with clear pink or purple fluid (Fig. 12.7), and cutaneous necrosis (Fig. 12.8), within 48 h. The skin becomes anesthetic and subcutaneous gas may be present. Systemic toxicity may be manifest by fever, dehydration, leukocytosis, and frequently positive blood cultures. Fournier's gangrene is a form of necrotizing fasciitis occurring in the groin and genitalia (see Figs. 8.9, 8.10). It is rapidly progressive and is associated with a high mortality rate, particularly in diabetics. The infection can pass through Buck's fascia of the penis, dartos fascia of the scrotum and penis, Colles' fascia of the perineum, and Scarpa's fascia of the abdominal wall. Two groups of organisms are implicated in necrotizing fasciitis. Type I includes anaerobic species (Bacteroides and Peptostreptococcus) and type II group A streptococci alone or with Staphylococcus aureus.
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    Last edited by trimurtulu; 01-09-2009 at 10:10 AM.

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