Role of fasciotomy in snake bite

cases: a report of 2 cases

Pramod Kumar MS, MCh, DNB, MBA, Esraa Alsayed MBBCh, Yahya Ibrahim
Najmi , MD, Mohd Mohd Hassan Elabd MS
INTRODUCTION

Snakebite

• Snake bites are wellknown medical emergency in many

parts of the world, especially in rural area.
• Agricultural workers and children are the most affected
• Incidence of snake bite mortality is high in South-East Asia

Snake venom

• may be hemotoxic, neurotoxic or local tissue toxic.

• Antivenom is the only effective antidote for snake venom
INTRODUCTION

Fasciotomy

• Fasciotomy consist one or more fascial incision

with the goal of decompression and restoration
of muscle perfusion
• Fasciotomy is a clinical procedure indicated
once clinical diagnosis of compartment
syndrome is made
• Fasciotomy is contraindicated when diagnosis of
compartment syndrome is made late
 Case Report I

Patient presentation

• 7 year, male, with snake bite right little finger

over middle phalanx approximately 6 hours
back
• Patient received anti snake venom in pediatrics
• Examination revealed dark blue discoloration of
skin over middle phalanx of little finger (due to
inoculated toxin) and rapidly proximally
progressing edema with tenderness
Patient presentation

• Tense edema up to middle of arm

• Passive extension produced excruciating pain
over forearm
• Oxygen saturation over fingers was less than 70%
• Hemoglobin = 11.5gm%
• CBC, Liver function test and renal function tests
within normal limits
 Patient underwent
emergency fasciotomy Post operative period : After edema settled in 3
of all fingers, dorsum of No extension of skin days time, preplaced
hand and forearm with necrosis sutures tied in minor OR
untied sutures in place.

On next day of tying

Follow up after 6 month
preplaced suture, few
showed mild Patient was discharged
additional sutures were
hypertrophy of forearm after one week.
applied to close the
scar.
wound.
 Fig 1. (a-f) Photograph of right upper limb of Case 1.
Showing limitation of necrosis over little finger following fasciotomy.
 Case Report II

Patient presentation

• 9 year, male, with snake bite right little finger

over middle phalanx approximately 8 hours
back
• Patient received anti snake venom in pediatrics
• Examination revealed dark blue discoloration of
skin over distal phalanx of little finger (due to
inoculated toxin) and slowly proximally
progressing edema with tenderness.
Patient presentation

•Tense edema up to the wrist

•Passive extension of fingers did not elicit
excruciating pain over forearm.
•The fingers were abducted with loss of baseline
MCP flexion and loss of IP extension (intrinsic minus
hand).
•Oxygen saturation over little fingers was less than
80% while over other fingers was 95-98%.
•Hemoglobin, CBC, Liver function test and renal
function tests were within normal limits.
 Patient underwent
emergency fasciotomy Post operative period :
of little finger and there was no extension
dorsum of hand with of skin necrosis.
untied sutures in place

After edema settled in

2 days, preplaced
sutures were tied in
minor OR

Follow up after 6 month

Patient was discharged
showed contracture of
after one week.
right little finger.
DISCUSSION

 American toxicology has advised not to perform

fasciotomy in snake bite cases in absence of direct
pressure measurement.
 At the end of their advice they have noted that it is
solely for informational purpose.
 Such advisory in the internet age, when many patients
and their relatives surf internet for diagnosis and
management advice, can cause confusion in medical
professional practice.
 In absence of direct pressure management in
compartment syndrome certain early clinical signs are
used as a guide to do fasciotomy
 Brawny edema
 Tenderness over involved compartment
 Excruciating pain over flexor compartment on
passive extension of fingers
 Findings in this study
Case I Case II
Oxygen Low Low
saturation
Tenderness Flexor compartment Tenderness,
tenderness and pain on Edema and intrinsic
passive extension of minus hand
fingers
Spo2 after Immediately improved Immediately improved
fasciotomy
Necrosis No extension of skin No extension of skin
necrosis necrosis
Functional Complete Complete
recovery
In contrast to this study findings

It was a case of some injury

Al-Azzawi and Al-Azzawi to knee area and not a
(2016) reported a case confirmed case of snake
where fasciotomy was bite. Snake bite was
not required suspected after 48 hours.

If for 48 hours, there was no vascular problem, the

compartment decompresion mostly will not be required
and hence, it would not be justified to consider this case
for advocating to cut or not to cut in snake bit cases.
 In agreement to this study findings

Snake bite cases need constant

Study by Dhar monitoring in a hospital setting for any
(2015) evolving compartment syndrome.

Early surgical decompression may prevent/limit established

gangrene and may be helpful in preserving limb function.
In agreement to this study findings

Fasciotomy allowed in
snake bite case for
intracompartment pressure
above 55 mmHg
Turkmen and Temel
(2016) proposed
recommendations
advocating fasciotomy
In children compartment
pressure may occur at
lower intracompartment
pressure.
In agreement to this study findings
Rowland (1975) has emphasized definite role of
fasciotomy for snake bite if there is question of tissue
viability proximally secondary to massive edema
(compartment syndrome)

Necrotizing factors
inoculated at the site of
Type and amount of
evenomation cause local
venom determines extent
necrosis, but proximal
and speed of necrosis.
necrosis occurs due to
massive edema
 Conclusion

 Snake bite necrosis at the site of evenomation occurs due to

toxins inoculated locally
 Proximal necrosis occurs if compartment syndrome
develops.
 Early signs of compartment syndrome and/ or direct
measurement of compartment pressure are indications of
fasciotomy to prevent/limit extent of tissue necrosis.
 Scarring, hypertrophy and contractures are long term
complications of fasciotomy.
 REFERENCES
1. http://www.choosingwisely.org/clinicianlists/ acmt-and-aact-fasciotomy-for-
snake-bites/ (Americantoxicology)

2. Al-Azzawi, M,. Al-Azzawi, AJK. Case report: Compartment syndrome secondary to

a snakebite; To cut or not to cut? Journal of Pediatric Surgery Case Reports. 2016;
11: 7-8.

3. Dhar D. Compartment Syndrome Following Snake Bite. Oman Medical Journal

2015;30: 1-4., DOI 10.5001/omj.2015.32

4. Türkmen A, Temel M. Algorithmic approach to the prevention of unnecessary

fasciotomy in extremity snake bite. Injury 2016; 47:2822-2827. doi:
10.1016/j.injury.2016.10.023.

5. Rowland SA. Early fasciotomy in the treatment of snake bite. Clinical

Orthopaedics and Related Research (Abstracts: Association of Bone and Joint
Surgeons Annual Meeting, 1975) 1975; 111:306.