No abstract

A 72-year-old woman presented with concern for a necrotising soft tissue infection (NSTI) 6 days after a tree branch impaled her left lower extremity while hiking in Hawaii. The wound was irrigated and closed at a local clinic in Hawaii. She completed a 5-day course of clindamycin. She presented to our emergency department 1 day after completion of antibiotics due to worsening erythema and malodorous drainage. Local wound exploration revealed bullae and easy dissection of fascial planes. CT scan revealed complex heterogeneous fluid and inflammatory stranding in the posterior calf. Clinical and radiographic findings raised concern for NSTI prompting initiation of broad spectrum antibiotics and urgent operative debridement. Wound cultures and deep tissues cultures returned positive for pansusceptible Leclercia adecarboxylata. She underwent two additional operative debridements and transitioned to negative pressure wound therapy during her hospitalisation. She was discharged home on oral amoxicillin/clavulanate on hospital day 6.

Complex repairs with adjunctive measures(CRAM) of duodenal injuries did not prevent leaks and did not reduce adverse sequelae when leaks did occur. This suggests CRAM is not a protective repair strategy and primary repair alone(PRA) should be pursued for all injuries if feasible.