Cellulitis

Cellulitis is diffuse swelling and redness of the leg associated with pain and fever. Skin is stretched and shiny. Inflammatory exu date (infectious material) spreads in the subcutaneous and fascial planes resulting in a gross swelling of the affected part. If swelling persists or increase in size, it can lead to compartment syndrome (increase in pressure in muscles compartment). This causes severe pain and if not relieved can have life threatening consequences due to spread to infection to whole body. In this condition, urgent Fasciotomy is required.

• Patient has to be admitted in hospital
• Routine investigations are done, pus and blood culture and sensitivity
• Start with broad spectrum antibiotics
• Bed rest with legs elevated, this will reduce edema.
• Digital x-ray of the affected region is necessary to rule out any bony infection.
• Regular Dressings are done with Magnesium sulphate, it further decreases swelling by osmotic effect.
• If there is improvement in the swelling, regular dressing is done, medications for 5-7days given and then discharged with oral medications and explained about further management.

If swelling persists or increase in size, leading to compartment syndrome (increase pressure in muscles compartment), then urgent Fasciotomy is required. After this regular dressing are done daily.

In cases of large and dirty wounds, debridement is done along with fasciotomy.

After initial fasciotomy and debridement, Negative Pressure Wound Therapy (VAC) before definite procedure is done to reduce the toxins and infection in the body.

Definite Procedure to close the wound are done last which may be skin grafting, local or free flaps as per the requirement.

• Once the wound is healthy, skin grafting may be done if defect is not much deep and vitals structures are embedded in granulation tissue. In such cases, dressing is done every alternate day after surgery. Patient may be discharged after 5-6days, and regular follow-up is required.
• If defect is deep, any vital structures are visible, like blood vessels, nerve, bone or tendons exposed, in such cases, local flaps or free flaps are done.
• If there is ample amount of good tissue present in the surrounding area, then local flap is done to cover the vital structures.
• If the surrounding area is not healthy and the defect is too big, the microvascular transfer of flaps (free flap) isdone. After surgery, flap is being monitored regularly every 2 hours in the beginning. Dressing is done every alternate day and patient is admitted for at least 7-8 days and discharged once the flap is settled.
• In untreated cases, gangrene may occur, infection may lead to toxemia and septicemia i.e, release of toxins in the body by infectious organisms. Amputation may be required in such cases. In worst cases, even lead to death.

Abscess

Localized collection of pus. It can be due to different types of infection and can be superficial or deep. Abscesses are quite common in the legs or foot region of diabetic patients but can develop in any part of the body. Patient will have throbbing pain around the abscess. Fever may be present. Hence incision and drainage surgery is required to treat the abscess.

In untreated cases, it may increase and point towards the weakest area in the skin and can burst spontaneously or can spread inward to lead to more fulminant infections like cellulitis and necrotizing fasciitis of the whole limb. Therefore timely intervention of any infection of the skin under proper guidance of a plastic surgeon is mandatory to stop further progression of the infection to the whole body.

In all these emergency situation, main goal of the treatment is to drain the pus, or any extra fluid, and relieve the patient from pain and save the life and leg by stopping further progression of the disease. Infection is controlled by confirming the organism through blood culture report and using appropriate antibiotics.

At the same time blood sugar levels to be monitored and controlled by using insulin injections or oral medications.

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