**5. Case report**

A 42-year-old female patient [12] who had previously been a victim of a motorcycle accident was attended to at a hospital unit in the interior of the state, diagnosed with a fracture of the middle third of the clavicle (Allman's group I) with deviation (>2 cm).

The physical examination showed no neurovascular deficit, no imminence of bone exposure at the fracture site, or apparent deformity, but she presented with right shoulder abrasions (posteriorly). Initially she was medicated with analgesics but has not received orientation about the use of a sling or necessity of follow-up with a specialist.

After the trauma (2 weeks), she presented with fever, local hyperemia, pain, and fever, requiring hospitalization (city of origin). She evolved local abscess (right clavicle region) and followed by spontaneous drainage of a purulent secretion (through a small orifice). Seventeen days after trauma, the patient underwent abscess drainage with 0.9% saline solution (in the ward) but no debridement (cultures/swab wasn't collected) (**Figure 1**). Results of laboratory exams are as follows: white blood cells (WBC), 2000/mm3 ; erythrocyte sedimentation rate (ESR), 25 mm/h; and C-reactive protein (CRP), 11 mm/dl. At this stage, intravenous antibiotic therapy was initiated (with clindamycin 600 mg 8/8 h, metronidazole 500 mg 8/8 h, and ceftriaxone 1 g 12/12 h) and was transferred to a referral hospital in orthopedics surgery in the city of Salvador-BA (Brazil).

#### *Pathogenic Bacteria*

Despite the use of intravenous antibiotics, she evolved with toxemia, sepsis (heart rate (HR), 110 bpm; respiration frequency (RF), 26 ripm; temperature, 38.5°C), and an extensive lesion of the right hemithorax and base of the neck (with necrosis) and clavicle bone exposure but no neurovascular alterations (**Figure 2**). Their exams evolved worse (21,000 WBC/mm3 ; ESR, 44 mm/h; CRP, 20 mm/dl, creatinine, 1.3 mg/dl; urea, 48 mg/dl; and CPK, 900 u/l), and the magnetic resonance imaging (MRI) of the thorax evidenced inflammatory process in the anterior region of the thorax (but no involving deep tissue layers), typical of Fournier's gangrene. Because of this clinical condition, she was admitted in the intensive care unit (ICU).

After clinical stabilization, the patient needed surgical debridement (with collected culture material), with clavicle preservation and modified antibiotic therapy (changed to vancomycin 1 g 12/12 h and meropenem 1 g 8/8 h).

The Fournier's gangrene continued with an increase in the necrotic area and of osteolysis in the clavicle exposure area. The orthopedics surgeons decided to perform a total clavicle resection with debridement (**Figure 3**). Two days after,

**Figure 1.** *Initial Fournier's gangrene of the shoulder girdle.*

**151**

**Figure 4.**

*Three months after grafting.*

**Figure 3.**

*Lesion before grafting.*

important clinical improvement.

(maybe due to previous use of antibiotics).

she evolved with a reduction of the WBC/inflammatory markers and presented an

The borders of the lesion ceased to evolve with necrosis and purulent secretion (granulation tissue started). The bone and soft tissue culture results were negative

Twenty days after the clavicle resection, with normal laboratory tests, a skin graft was performed by the plastic's surgeon. The patient was discharged from

*Fournier's Gangrene of the Shoulder Girdle DOI: http://dx.doi.org/10.5772/intechopen.92385*

**Figure 2.** *Evolution of Fournier's gangrene of the shoulder girdle.*

*Fournier's Gangrene of the Shoulder Girdle DOI: http://dx.doi.org/10.5772/intechopen.92385*

*Pathogenic Bacteria*

unit (ICU).

Their exams evolved worse (21,000 WBC/mm3

Despite the use of intravenous antibiotics, she evolved with toxemia, sepsis (heart rate (HR), 110 bpm; respiration frequency (RF), 26 ripm; temperature, 38.5°C), and an extensive lesion of the right hemithorax and base of the neck (with necrosis) and clavicle bone exposure but no neurovascular alterations (**Figure 2**).

creatinine, 1.3 mg/dl; urea, 48 mg/dl; and CPK, 900 u/l), and the magnetic resonance imaging (MRI) of the thorax evidenced inflammatory process in the anterior region of the thorax (but no involving deep tissue layers), typical of Fournier's gangrene. Because of this clinical condition, she was admitted in the intensive care

After clinical stabilization, the patient needed surgical debridement (with collected culture material), with clavicle preservation and modified antibiotic therapy

The Fournier's gangrene continued with an increase in the necrotic area and of osteolysis in the clavicle exposure area. The orthopedics surgeons decided to perform a total clavicle resection with debridement (**Figure 3**). Two days after,

(changed to vancomycin 1 g 12/12 h and meropenem 1 g 8/8 h).

; ESR, 44 mm/h; CRP, 20 mm/dl,

**150**

**Figure 2.**

**Figure 1.**

*Evolution of Fournier's gangrene of the shoulder girdle.*

*Initial Fournier's gangrene of the shoulder girdle.*

**Figure 3.** *Lesion before grafting.*

**Figure 4.** *Three months after grafting.*

she evolved with a reduction of the WBC/inflammatory markers and presented an important clinical improvement.

The borders of the lesion ceased to evolve with necrosis and purulent secretion (granulation tissue started). The bone and soft tissue culture results were negative (maybe due to previous use of antibiotics).

Twenty days after the clavicle resection, with normal laboratory tests, a skin graft was performed by the plastic's surgeon. The patient was discharged from

#### **Figure 5.**

*Six months after the procedure, the patient presented excellent functional results and a completely healed wound.*

the hospital after evolving without new signs of infection. The wound presented complete healing of the graft after 60 days **(Figure 4)**.

At the last outpatient visit (after 6 months of trauma), the patient presented excellent upper limb function (33 points on the UCLA score and 93 points on the constant score) **(Figure 5)**.

### **6. Treatment**

Once the diagnosis is established, treatment must be instituted immediately and consists of volume replacement; ample surgical debridement, with removal of all necrotic material, including the fascia; and the use of broad-spectrum antibiotics.

Although didactic, the classification of NF, in types I–IV, has little practical utility and should not be decisive in the choice of antimicrobials. The polymicrobial form is responsible in 80% of cases, which justifies the initial broad-spectrum empirical antibiotic therapy, formed by the association of clindamycin, with aminoglycoside or ciprofloxacin, used in the reported cases. Recently, the American Society of Infectious Diseases indicated the combination of ampicillin-sulbactam, clindamycin, and ciprofloxacin as the scheme of choice for community-acquired infections. In cases of nosocomial infection, the association of carbapenems with anaerobicides is indicated, according to the profile sensitivity of the most prevalent bacteria in the institution [10].

**153**

**Author details**

Gyoguevara Patriota1

**Conflict of interest**

Paulo Santoro Belangero2

Paulo/UNIFESP, São Paulo, Brazil

provided the original work is properly cited.

\*, Luiz Marcelo Bastos Leite1

The authors do not have any conflicts of interest to declare.

\*Address all correspondence to: ombroecotovelo@drpatriota.com.br

1 Cardiopulmonar Hospital – Salvador-BA, Salvador, Brazil

and Benno Ejnisman2

2 Sports Medicine Division, Orthopaedics Department, Federal University of São

© 2020 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/ by/3.0), which permits unrestricted use, distribution, and reproduction in any medium,

Mallikarjuna et al. [24] described the treatment of Fournier's gangrene consists of drainage, radical debridement of the necrotic tissues, and antibiotic therapy for approximately 4 to 6 weeks (initially with ampicillin/sulbactam or ampicillin combined with clindamycin or metronidazole and de-escalation guided by culture results), plus good hemodynamic stabilization. Hyperbaric oxygen therapy (OH) and the use of immunoglobulins are adjuvant and remain controversial; at the same time, further studies are needed before they can be recommended [24, 25]. The use of a vacuum drain dressing has shown to be beneficial in the follow-up after debridement; this dressing should be changed every 24–72 h [26]. Tetanus prophylaxis should be performed; however, randomized controlled trials are still required to prove the efficacy of the use of immunoglobulins as a neutralizer of *Streptococcus* toxins [27]. After the absence of infectious sign and clinical stabilization, reconstructive surgery would could be performed with grafting (if necessary) [28].

, Nivaldo Cardozo Filho1

,

*Fournier's Gangrene of the Shoulder Girdle DOI: http://dx.doi.org/10.5772/intechopen.92385*

### *Fournier's Gangrene of the Shoulder Girdle DOI: http://dx.doi.org/10.5772/intechopen.92385*

*Pathogenic Bacteria*

the hospital after evolving without new signs of infection. The wound presented

*Six months after the procedure, the patient presented excellent functional results and a completely healed* 

At the last outpatient visit (after 6 months of trauma), the patient presented excellent upper limb function (33 points on the UCLA score and 93 points on the

Once the diagnosis is established, treatment must be instituted immediately and consists of volume replacement; ample surgical debridement, with removal of all necrotic material, including the fascia; and the use of broad-spectrum

Although didactic, the classification of NF, in types I–IV, has little practical utility and should not be decisive in the choice of antimicrobials. The polymicrobial form is responsible in 80% of cases, which justifies the initial broad-spectrum empirical antibiotic therapy, formed by the association of clindamycin, with

aminoglycoside or ciprofloxacin, used in the reported cases. Recently, the American Society of Infectious Diseases indicated the combination of ampicillin-sulbactam, clindamycin, and ciprofloxacin as the scheme of choice for community-acquired infections. In cases of nosocomial infection, the association of carbapenems with anaerobicides is indicated, according to the profile sensitivity of the most prevalent

complete healing of the graft after 60 days **(Figure 4)**.

constant score) **(Figure 5)**.

bacteria in the institution [10].

**6. Treatment**

**Figure 5.**

*wound.*

antibiotics.

**152**

Mallikarjuna et al. [24] described the treatment of Fournier's gangrene consists of drainage, radical debridement of the necrotic tissues, and antibiotic therapy for approximately 4 to 6 weeks (initially with ampicillin/sulbactam or ampicillin combined with clindamycin or metronidazole and de-escalation guided by culture results), plus good hemodynamic stabilization. Hyperbaric oxygen therapy (OH) and the use of immunoglobulins are adjuvant and remain controversial; at the same time, further studies are needed before they can be recommended [24, 25]. The use of a vacuum drain dressing has shown to be beneficial in the follow-up after debridement; this dressing should be changed every 24–72 h [26]. Tetanus prophylaxis should be performed; however, randomized controlled trials are still required to prove the efficacy of the use of immunoglobulins as a neutralizer of *Streptococcus* toxins [27]. After the absence of infectious sign and clinical stabilization, reconstructive surgery would could be performed with grafting (if necessary) [28].
