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Exclusion of Necrotizing Soft-tissue Infection in a Patient with Malpositioned Intraosseous Access: A Case Report
Christopher R Leland1,2, Hannah H Nam1,2, David N Bernstein1,2
1Harvard Combined Orthopaedic Residency Program, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA.
Introduction:
Necrotizing soft-tissue infection (NSTI) is a life- and limb-threatening diagnosis, warranting careful evaluation. However, intra-articular gas and soft-tissue emphysema, which are commonly associated with NSTI, may also be observed after traumatic arthrotomy, joint dislocation, and prior instrumentation.
Case Report:
We present a 59-year-old woman in extremis from septic shock with left glenohumeral joint pneumarthrosis and emphysema extending to her posterior scapular musculature. While concerning for NSTI, physical examination was discordant. Review of pre-transfer documentation revealed prior instrumentation with an intraosseous line that pierced the left acromion process and violated the glenohumeral joint space.
Conclusion:
NSTI is a critical diagnosis, particularly in the sick patient with hemodynamic instability, poor infectious source control, and soft-tissue emphysema. Discordant physical examination should raise suspicion for other etiologies such as traumatic arthrotomy, joint dislocation, or recent instrumentation.
Insights
Necrotizing soft-tissue infection (NSTI) can mimic other conditions. Intra-articular gas and emphysema after instrumentation may not indicate NSTI, necessitating careful evaluation of patient history and discordant physical exams.
Area of Science:
- Orthopedic Surgery
- Infectious Disease
- Radiology
Background:
- Necrotizing soft-tissue infection (NSTI) is a severe condition requiring prompt diagnosis.
- Intra-articular gas and soft-tissue emphysema are common findings in NSTI.
- However, these findings can also occur after joint trauma or instrumentation.
