An 11-year-old girl was bitten by an unidentified snake on the volar aspect of her left forearm while playing at the farm. A tourniquet was tied on her arm for an unknown duration and traditional medicine applied to the wound. Initially, the forearm pain was sharp but gradually evolved to a severe throbbing pain spreading to the chest wall with associated swelling of the affected regions. A day later, the child was taken to her local hospital where fever and rapidly advancing dark-brown discolouration of the forearm was noted. She was then transferred to our facility due to toxaemia, arriving 6 days following the bite. There was no history suggestive of systemic envenomation and she had no known chronic illness.
On admission, she was ill-looking with a temperature of 38.4 C, tachycardia and tachypnoea. She was pale with haemoglobin level at 8.2 g/dL, white blood cell count at 14.6 x 103, neutrophilia and platelet count at 53 x 103. Local examination revealed patchy dark-brown skin discoloration of the upper limb and anterior chest with multiple foul-smelling skin blisters. The skin of the forearm and hand was tense and tender with visible bite marks. The tenderness was exacerbated by passive movement of the fingers; however, the hand remained pink and warm with a palpable pulse.
A diagnosis of necrotizing fasciitis with acute compartment syndrome was made, and the patient was taken to theatre for surgical fasciotomy and debridement. Intraoperative findings included extensive soft tissue necrosis with overlying dermal gangrene and multiple pockets of pus in the arm, hand and anterior chest wall. Forearm fasciotomy was performed, and muscles bulged out revealing pale non-contractile muscles with poor bleeders. The skin blisters were de-roofed, pus drained and wounds washed. Minimal debridement was done to reduce operating time as the patient's condition was critical. The muscles were left intact and the wounds dressed. Postoperatively, high-flow oxygen, whole blood, analgesics and high-dose antibiotics were commenced along with a high-protein diet and micronutrient supplements. The parents were counselled on the possibility of amputation if the limb showed no recovery on the second-look debridement scheduled at 48 h. Following the operation, fevers settled and the child recorded a good urine output.
During second-look debridement, the muscles were found to have recovered. Minimal pus was found, though the dermal gangrene had extended to include most of the upper limb and the chest up to the level of the xiphoid process (Figure 1). The underlying necrosis of the subcutaneous tissue extended beneath the viable skin of the anterior chest wall to the mid-axillary lines bilaterally. Multiple drains were inserted into the fascial plane to drain the anticipated fluid and pus under the skin pockets. The forearm tendons exposed following fasciotomy were covered by approximating the skin.
Staged debridement was repeated every 48 h with the patient making steady recovery. However, 6 days post admission she developed an intermittent dry cough associated with central chest pain. She was tachycardic with bilateral pitting pedal oedema. Chest x-ray showed widening of the mediastinum with clear lung fields (Figure 2). Pus was noted at the jugular notch draining from the mediastinum and a diagnosis of mediastinitis was made. A drain was placed beneath the jugular notch, diuretics started and the patient nursed in Trendelenburg position to facilitate pus drainage. A week later, the chest pain and cough decreased, and the mediastinum pus drainage ceased with repeat x-rays showing resolution of the mediastinal widening (Figure 3).
Wound reconstruction was performed 22 days post admission (Figure 4). A split-thickness skin graft harvested from the lower limbs was meshed by hand and secured onto the wound. A sheet (not meshed) thick-split skin graft was used to cover the flexural area of the elbow joint. In total, 20% of total body surface area (TBSA) was grafted with a local flap mobilized and used to complete coverage of the left axilla. The skin at the base of the neck was sutured to achieve secondary closure and a plaster splint applied with the elbow semi-flexed at 120  and the hand in functional position.
Graft wounds were exposed on day 5 with good take of the graft except 0.5% TBSA on the back that sheared off earlier during movement of the child on the ward and dehiscence of the lower neck sutured wound (Figure 5). Donor site wounds were exposed on day 15 and healed well. Hand function was compromised with reduced power and movement of the ring and little finger while returning the ability to hold a pencil using her thumb and index finger. Physiotherapy was commenced and the child was discharged.