Physical Examination Findings in Necrotizing Fasciitis
In a 64-year-old man with suspected necrotizing fasciitis, the most likely physical examination finding would be edema and crepitus (gas in tissues), often accompanied by skin necrosis or ecchymoses. 1, 2
Key Diagnostic Physical Findings
The physical examination in necrotizing fasciitis reveals several characteristic features that distinguish it from simple cellulitis:
Most Common Findings
Edema is present in approximately 80% of cases and represents a critical diagnostic feature, with edema or tenderness extending beyond the cutaneous erythema being a cardinal sign of deeper tissue involvement. 1
Crepitus (subcutaneous emphysema) indicating gas in tissues is a highly specific finding that occurs commonly in necrotizing fasciitis and helps differentiate it from superficial infections. 3, 1, 2
Skin necrosis, ecchymoses, or bullous lesions are present in 70% of cases, making these important diagnostic clues when present. 1
Critical Distinguishing Features
Severe pain disproportionate to clinical findings is the hallmark early symptom that should raise immediate suspicion for necrotizing fasciitis. 1, 2
A hard, "wooden" feel of subcutaneous tissue extending beyond apparent skin involvement distinguishes fasciitis from cellulitis, where tissues remain palpable and yielding. 1, 2
Systemic toxicity with altered mental status, fever, and signs of sepsis are characteristic features that indicate deep tissue involvement. 1, 2
Why the Other Options Are Less Likely
Diminished distal pulses would suggest vascular compromise or compartment syndrome rather than necrotizing fasciitis specifically. 1
Yellow crusted lesions are more consistent with impetigo or other superficial bacterial infections. 1
Plaques with sharply demarcated borders and raised edges with scaling describe psoriasis or other dermatologic conditions, not necrotizing fasciitis. 1
Critical Clinical Pitfall
The most dangerous pitfall is that cutaneous manifestations tend to appear later in the disease process, meaning early necrotizing fasciitis may show relatively benign skin findings despite severe underlying fascial necrosis. 3 This is why pain disproportionate to examination findings is so critical—it signals deep tissue involvement before obvious skin changes develop. 1, 2
Immediate Action Required
When necrotizing fasciitis is suspected based on any combination of these findings—particularly pain out of proportion, woody induration, crepitus, or systemic toxicity—proceed immediately to surgical exploration rather than continuing conservative management, as delay in diagnosis correlates directly with mortality. 1, 4
Do not wait for imaging studies when clinical suspicion is high; surgical exploration is both diagnostic and therapeutic. 2, 4