Clinical presentation

Latency between contamination and signs of infection is usually short -between 12 and 24 hours. A pale and non-healing wound may sometimes prompt clinical suspicion. The first local signs are sharp and increasing pain - sometimes disproportionate to the size of the injury; anxiety and apprehension again exceeding the norm; cold and discoloured skin, extensive oedema, and a small amount of exudate. This is the stage where diagnosis must be considered and the wound investigated.

Radiography of the soft tissue can show gas bubbles or "feathering" in muscles thus providing an element of confirmation, but gas may not be present in the tissues at the onset and is not a reliable finding (i.e., only 20 % of cases, in our experience). Accordingly this element must not be a prerequisite for diagnosis. Bacteriological findings and surgical observation are the most important indicators. Moreover, the presence of gas is not specific: there are other gas-producing germs: (E. coli, Proteus, Aerobacter, etc.) and the trauma itself may have caused a misleading injection of air into soft tissue. The latter may be considered where gas is demonstrated by crepitus and radiographs taken very soon after the traumatic injury in the absence of developing sepsis.

The diagnosis of anaerobic myonecrosis is therefore first and foremost a clinical one. Bacteriological confirmation takes time and delay runs the risk of a rapid propagation with ensuing hypotension, altered consciousness, oliguria, jaundice and coagulopathy - all of which are signs of a poor ultimate outcome28.

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