A misdiagnosed burn: necrotising fasciitis in an elderly patient

Abstract

A 91-year-old man was admitted having been found unresponsive in his bed. He was previously well, but had sustained a laceration over the dorsum of his forearm after a recent fall. Initial appearances were innocuous, and suggestive of a superficial wound infection. A review of the wound by the plastic surgeons led to the diagnosis of a full-thickness burn, despite a lack of supporting evidence in the history. No clinician who had initially assessed the patient was involved in his ongoing care. Rapid clinical deterioration ensued, with sepsis and deteriorating mental state. Necrosis spread rapidly up his arm, and the diagnosis of necrotising fasciitis was made. The patient was urgently taken to theatre for circumferential excision of the necrotic tissue. He was subsequently managed on the intensive care unit where he made a promising initial recovery, but later died from pneumonia in the ward.

Figure 1

Preoperative appearance of dorsal aspect of patient's upper limb.

Figure 2

Preoperative appearance of volar aspect of patient's upper limb.

Figure 3

Postoperative appearance of dorsal aspect of patient's upper limb.

Figure 4

Postoperative appearance of volar aspect of patient's upper limb.