RESUMO
Abstract Clavicle fracture represents 5% of the fractures in adults. However, segmental clavicle fractures are infrequent and have been understudied in the current literature. Cases have been reported showing adequate results with both surgical and conservative management, and yet, it has not been possible to reach a consensus regarding diagnosis or management of such condition. A patient with a middle and lateral segmental clavicle fracture is reported, after presenting multiple trauma in a road traffic accident, also suffering trauma to the right hemi body, multiple rib segmental fractures and hemothorax. After stabilization, he was taken to surgery for open reduction and internal fixation of the clavicle using a double plate technique, as it has been rarely described in the literature. The functional result was shown to be adequate and satisfactory in the postoperative follow-up. Despite the limited evidence available on the management of this type of pathology, surgical management is a valid option given the risk of non-union. The foregoing is concluded by the potential harm in patient functionality.
Resumo A fratura de clavícula representa 5% das fraturas em adultos. No entanto, as fraturas segmentares da clavícula são infrequentes e pouco estudadas na literatura atual. Há relatos de casos com bons resultados após o tratamento cirúrgico ou conservador, mas não existe consenso quanto ao diagnóstico ou manejo dessas lesões. Relata-se um paciente com fratura segmentar média e lateral da clavícula após politraumatismo em acidente de trânsito. O paciente também apresentava traumatismo em hemicorpo direito, múltiplas fraturas segmentares da costela e do hemotórax. Após estabilização, ele foi encaminhado à cirurgia para redução aberta e fixação interna da clavícula pela técnica de placa dupla, raramente descrita na literatura. O resultado funcional foi considerado satisfatório e adequado no acompanhamento pós-operatório. Apesar das poucas evidências sobre o manejo desse tipo de patologia, o tratamento cirúrgico é uma opção válida devido ao risco de não união, apesar da possível diminuição da funcionalidade do paciente.
RESUMO
La presentación de poliartritis séptica en un paciente inmunocompetente es infrecuente, aún más lo es la presentación de la mencionada junto con fascitis necrotizante en el contexto de infección por Streptococcus Pyogenes (SP). Se presenta el caso de un paciente masculino de 54 años, recluido, sin antecedentes médicos relevantes, inmunocompetente, quien debuta con un cuadro clínico de poliartritis séptica en rodilla bilateral y tobillo izquierdo. Recibe manejo con múltiples lavados y desbridamientos quirúrgicos, desarrolla fascitis necrotizante de la cara posterior de la pierna izquierda, recibe a su vez manejo quirúrgico para dicha condición (incluyendo aplicación de terapia de vacío), al igual que antibioticoterapia enfocada al manejo del germen aislado (Penicilina + vancomicina). Sin embargo, tras un mes de manejo conjunto con servicios de Cirugía Plástica, Dermatología, Ortopedia, así como vigilancia en Unidad de Cuidados Intensivos, termina con un desenlace fatal tras presentar falla multiorgánica. La infección por el SP puede resultar en una elevada morbilidad para él paciente e incluso un desenlace mortal secundario a un compromiso sistémico de muy difícil manejo. El diagnóstico oportuno, así como un tratamiento médico y quirúrgico agresivo pueden no ser suficientes para el control de la infección, incluso en pacientes sin compromiso inmunológico previo. Asimismo, un enfoque multidisciplinario debe corresponder al estándar de manejo con el fin de controlar aquellas condiciones predisponentes de infección. Este es el primer caso reportado en la literatura nacional en relación con estas dos fatales condiciones. Finalmente se pretende resaltar que a pesar de que esta infección suele comprometer infantes y pacientes inmunocomprometidos, no se debe obviar su diagnóstico en pacientes previamente sanos, especialmente en casos de infecciones de rápida diseminación y poca respuesta al manejo adecuado.
Septic polyarthritis in an immunocompetent patient is highly rare, even more when it coexists with necrotizing fasciitis caused by Streptococcus Pyogenes (SP). A 54 year old, immunocompetent male patient is presented herein. The patient had no relevant previous illness, before the installation of a septic arthritis of both knees and he's left ankle. He receives treatment with sequential surgical debridement, then develops necrotizing fasciitis of the posterior aspect of the left leg requiring adequate treatment for such condition (including Vacuum Assisted Closure), as well as antibiotic therapy for the specific infecting microorganism (Penicillin + Vancomycin). Nonetheless, after a month of surgical management between Plastic Surgery, Dermatology, Orthopaedics as well as surveillance in the Intensive Care Unit, the patient dies after multi organic failure. Infection caused by SP might entail high morbidity for a patient and even end with death of the aforementioned caused by a hard to manage systemic organic failure. The adequate diagnosis, as well as aggressive medical and surgical management could not be enough for controlling the infection, even in patients without previous immunological compromise. At the same time, a multidisciplinary approach must be the standard of treatment, aiming to control predisposing infectious conditions. This is the first case reported in national literature related to these two fatal conditions. Finally, one of the purposes of this report is to highlight that despite reports of this microorganism infecting infants and immunocompromised patients, it must not be obviated in healthy patients, especially in cases of rapidly spreading infection and scarce response to adequate management.