Comprehensive management of diabetic cellulitis in hand and its outcome
Amuthakani. V1, Angel Roselin. S2
1Nursing Supervisor Post-operative ward, Kauvery Hospital, Tirunelveli, Tamil Nadu
2DNS, Kauvery Hospital Tirunelveli, Tamil Nadu
Abstract
Cellulitis is a bacterial skin infection affecting the deeper layers of the skin and underlying tissue. It often presents as a red, swollen, painful, and warm area of skin. Prompt treatment with antibiotics is crucial to prevent serious complications. Cellulitis usually affects the lower legs, but it can occur on the face, arms and other areas. This infection happens when a break in the skin allows bacteria to enter. If untreated, the infection can spread to the lymph nodes and bloodstream and rapidly become life-threatening. It doesn’t usually spread from person to person.
Background
The term cellulitis is commonly used to indicate a non-necrotizing inflammation of the skin and subcutaneous tissues, a process usually related to acute infection that does not involve the fascia or muscles. Cellulitis is characterized by localized pain, swelling, tenderness, erythema, and warmth.
Cellulitis has been classically considered to be an infection without formation of abscess (non-purulent), purulent drainage, or ulceration. At times, cellulitis may overlap with other conditions, so that the macular erythema coexists with nodules, areas of ulceration, and frank abscess formation (purulent cellulitis).
A population-based database had examined cellulitis incidence, anatomical sites of infection, complicating diagnoses, source of health service, and recurrence rates. Files were searched for cellulitis ICD-9-CM codes 681.0–682.9. Complications of cellulitis including erysipelas, lymphadenitis, lymphangitis, and necrotizing fasciitis were also identified by ICD-9-CM codes. They found a cellulitis incidence rate of 24·6/1000 person-years, with a higher incidence among males and individuals aged 45–64 years. The most common site of infection was the lower extremity (39·9%). The majority of patients were seen in an outpatient setting (73·8%), and most (82·0%) had only one episode of cellulitis during the 5-year period studied. There was a very low incidence of cellulitis complications, including necrotizing fasciitis.
Cellulitis is fairly common, usually treated in outpatient settings, and is infrequently complicated by erysipelas, lymphadenitis, lymphangitis, or necrotizing fasciitis. (Cellulitis incidences a defined population 2005 Sep 7;134(2):293–299).
Outcome
The outcome of cellulitis with prompt treatment, has a good prognosis, with symptoms improving within 48 hours. However, if left untreated, cellulitis can lead to serious complications like sepsis, lymphangitis, abscess formation, or even tissue death. Recurrent cellulitis can also damage the lymphatic system, causing chronic swelling.
Case Presentation
The patient was a 71yrs aged male, with clinical history DM/ CAD – S/P CABG/ Old CVA,
O/E patient was drowsy, arousable, disoriented.
Planned for wound debridement under anesthesia LA /RA, after PT / INR reports.
Initially patient was started on antibiotics (Inj. Xone), Inj. Tramadol 1 amp, Inj. Pan 40 mg.
Medical Gastroenterologist opinion obtained for chronic calcific pancreatitis and orders were followed.
Cardiologist opinion was obtained for CAD / S/P CABG. ECHO showed CAD involving LAD/RCA territory, moderate LV systolic dysfunction, stage I diastolic dysfunction, MR (mild), TR (mild) IVS scarred & thinned out. Antiplatelet drugs were withheld before surgery.
Routine and relevant investigations were taken. Reports showed
Hb – 11,
Total count – 14270,
PT – 16,
INR – 1.22.
RBS – 202.
HbA1C – 7.8,
Lipid profile showed
Total Cholesterol – 121,
Triglycerides – 410.
General physician opinion obtained for glycemic control.
Neurologist opinion obtained for Old CVA.
Clinical Signs and Symptoms
- Necrotic patch 8 × 6 cm (+) over aspect of distal left forearm near wrist.
- Diffuse swelling over right hand left forearm.
- Warmth (+)
- Induration (+)
- Left Radial Pulse (+)
- Edema (Swelling)
Diagnosis
- Cellulitis with Necrotizing Fasciitis Left Upper Limb
- Type 2 Diabetes Mellitus for 15 years
- CAD – S/P CABG 15 Years Back
- Old CVA
Detailed Investigation
| 14.04.25 | Hemoglobin | 11.5 g/dl |
|---|---|---|
| Packed Cell Volume (PCV) | 37.0 | |
| Mean Corpuscular Volume (MCV) | 71.8 | |
| MCH (Mean Corpuscular Hemoglobin) | 22.3 | |
| MCHC (Mean Corpuscular Hemoglobin Concentration) | 31.1 | |
| 18.04.25 | Total WBC Count | 14270 |
| Neutrophil | 86.8 | |
| Lymphocyte | 5.7 | |
| Eosinophil | 0.7 | |
| Test (PT) | 16.2 Sec | |
| Control (PT) | 13.5 Sec | |
| INR | 1.22 | |
| Random Blood Sugar | 202.74 mg/dl | |
| Urea Serum | 56.95 (Rechecked) | |
| Creatinine | 1.00 | |
| Sodium | 130.0 | |
| Potassium | 4.19 | |
| HIV Rapid | Nonreactive | |
| HBsAg – Hepatitis B surface Antigen | Nonreactive | |
| Anti HCV Rapid | Nonreactive | |
| Total Bilirubin | 0.50 | |
| Direct Bilirubin | 0.20 | |
| Indirect Bilirubin | 0.30 | |
| Albumin | 4.90 | |
| Globulin | 2.60 |
19.04.25: Culture Tissue – No growth.
Doppler study showed normal doppler study of arteries of left upper limb.
No significant stenosis or occlusion was seen. Diffuse soft tissue edema seen in left forearm and dorsum of hand – cellulitis. Doppler Report:
On 19/04/2025 wound debridement with fasciotomy and abscess drainage done. Post procedure uneventful. Patient was treated with antibiotics, analgesic, PPI and other supportive drugs. Advised for left upper limb elevation.
Surgical Management
Wound debridement with fasciotomy and abscess drainage
On follow up: Wound was healthy and healing. Patient diet is modified and had good control of diabetic status
Review of the Literature
Management
Antibiotic regimens are effective in more than 90% of patients. However, all but the smallest of abscesses should undergo incision and drainage, regardless of the microbiology of the infection. In some instances, if the abscess is relatively isolated with little surrounding tissue involvement, drainage may suffice without the need for antibiotics.
Note that management of cellulitis may be complicated because of the emergence of methicillin-resistant Staphylococcus aureus (MRSA) and macrolide- or erythromycin-resistant Streptococcus pyogenes. Nonsevere cases of cellulitis may be treated empirically with semisynthetic penicillin, first- or second-generation oral cephalosporins, macrolides, or clindamycin.
Unfortunately, for patients with cellulitis surrounding abscess formation, 50% of MRSA strains also have inducible or constitutive clindamycin resistance. Of the strains of S. pyogenes resistant to macrolides, 99.5% seem to remain susceptible to clindamycin and 100% to penicillin. Most community-acquired MRSA infections (CA-MRSA) are apparently susceptible to trimethoprim-sulfamethoxazole and tetracycline.
*Source: https://emedicine.medscape.com/article/214222-treatment?form=fpf)
Surgical Management
A fasciotomy is an emergency procedure used to treat acute compartment syndrome. Compartment syndrome is when the pressure builds up in a non-compliant Osseo fascial compartment and causes ischemia leading to muscle and nerve necrosis. It occurs most commonly in the volar compartment of the forearm, deep posterior, or anterior leg compartment. It can however, happen in any closed space where the muscle is surrounded by substantial fascia, e.g., hand, foot, thigh, or buttock.
Compartment syndrome categorizes as acute or chronic. Acute compartment syndrome often follows high-energy trauma, fractures, circumferential burns, crush injuries, or a tight plaster cast. Chronic compartment syndrome develops with muscular overuse and commonly occurs in the leg of runners or military personnel or the forearm of weightlifters and rowers. Occasionally acute exertional compartment syndrome can be seen after strenuous exertion.
Technique or Treatment
Single-Incision Fasciotomy of the Leg (Davey, Rorabeck, and Fowler Technique)
- Make a skin incision beginning at the lateral malleolus and extending proximally along the fibula for the full length of the compartment.
- Develop the subcutaneous plane anteriorly to expose the fascial layer. Be aware of damage to the superficial peroneal nerve at this stage.
- Make a longitudinal incision in the anterior and lateral fascial compartments.
- Develop the subcutaneous plane posteriorly and perform a longitudinal incision into the superficial posterior compartment.
- Identify the soleus in the superficial posterior compartment and begin to develop the plane between the distal third of the soleus and the lateral compartment.
- Remove the soleus and the deeper flexor hallucis longus from the posterior fibula. Be aware the peroneal neurovascular bundle will be immediately medial to the fibula.
- Retract the peroneal vessels posteriorly to expose the fascial attachment of the tibialis posterior to the fibula and make a longitudinal incision.
- Apply appropriate wound dressing.
Double Incision Fasciotomy of the Leg (Mubarak and Harges Technique)
Anterolateral incision
-
- Make a 20 cm anterior skin incision centered between the crest of the tibia and the fibula.
- Identify the anterior intramuscular septum and make a longitudinal incision on either side into the anterior and lateral compartments.
Posteromedial incision
-
- Make a second skin incision starting 2 cm proximal and 2 cm superior to the medial malleolus of the tibia, extending proximally in line with the tibia longitudinally.
- Carefully use blunt dissection to identify the fascial layer, the long saphenous vein, and the saphenous nerve; retract these anteriorly.
- Make an incision along the length of the posterior fascial compartment.
- Make another fascial incision over the flexor digitorum longus muscle immediately posterior and medial to the tibia to release the posterior compartment.
Forearm Fasciotomy
- Volar Incision
- Make a large skin incision starting just radial to the flexor carpi ulnaris and extending proximally to the medial epicondyle.
- Extend the incision distally to the wrist crease, cross the wrist crease diagonally towards the hypothenar eminence and into the palm to facilitate a carpal tunnel release.
- Make a longitudinal incision into the superficial fascial compartment.
- Retract the flexor carpi ulnaris and the ulnar neurovascular bundle medially.
- Retract the flexor digitorum superficialis medially. This exposes the deep fascial compartment.
- Make a fascial incision onto the flexor digitorum profundus.
- Extend both fascial incisions to the transverse carpal ligament.
Dorsal Incision
-
- Make a 10-cm incision in the skin between the extensor digitorum communis and extensor carpi radialis brevis starting 2 cm distal to the lateral epicondyle. This incision allows the release of the fascia over the mobile wad immediately.
- Develop the subcutaneous plane posteriorly to expose the extensor retinaculum and release the fascia to decompress the posterior compartment.
Follow-up
Fasciotomy wound management begins with an inspection at 48 hours. If the compartments are soft, this closure is achieved by primary wound closure, secondary wound healing, or split-thickness skin grafting. Split-thickness grafting is needed in approximately 50% of wounds. Delayed primary closure is also feasible using a vessel loop shoelace stitch. The use of a negative pressure wound management device is another option.
Complications
Due to muscle necrosis and rhabdomyolysis, acute renal failure are common; treatment is with intravenous fluids and dialysis.
Incomplete fasciotomies can create a need for a revision fasciotomy either to extend the fascial opening or open a missed compartment. Compartments are most commonly overlooked when the anatomy is highly distorted, such as in cases of high-energy trauma or patients with previous surgery and scarring. In these patients, the associated mortality is increased by 4 times.
Also, patients who underwent a delayed fasciotomy have twice the amputation rate and 3 times the mortality. In some cases, even with timely fasciotomies, the affected limb may not regain normal functionality and may result in an amputation.
Wound Complications are as follows:
- Need for skin grafting
- Scaring
- Tendon tethering
- Muscle herniation
- Recurrent ulceration
- Swollen limbs
- Discolored wounds
- Pruritus
- Dry, scaly skin
- Altered sensation
Clinical Significance
Early recognition and subsequent treatment of compartment syndrome with fasciotomies cause a significant decrease in poor functional outcomes, the need for amputation, and the risk of death. Additionally, the medico-legal burden of delayed fasciotomies is high. The time from symptom onset to fasciotomy is directly linked to an increasing payout in medical negligence claims. Fasciotomy performed early is associated with a successful defense of medico-legal action.
Enhancing Healthcare Team Outcomes
Early recognition of compartment syndrome is best detected by those professionals who have regular contact with the patients in the hospital. The hospital staff, typically attending physicians and nursing staff, has the most contact time with patients and is in the best position to detect increasing symptom severity. These staff members need the most training in recognizing compartment syndrome and need to exercise a high index of suspicion. The ability to escalate the situation in a timely fashion to a senior physician who can initiate early aggressive treatment with fasciotomy is crucial. Therefore, department management is responsible for ensuring all healthcare team members have adequate training in recognizing the symptoms, familiarity with pressure measuring equipment, and can escalate the situation appropriately and promptly. Implementing an inter-professional approach provides the best method for early detection to provide the best patient outcomes.
