A COASTAL FISHERMAN'S BIGGEST CATCH: HAND SALVAGE AND FUNCTIONAL RECOVERY FOLLOWING MARINE FLESH-EATING BACTERIAL INFECTION

Objectives: A 47-year-old left-hand-dominant fisherman sustained a single fishhook puncture to the right thumb in Louisiana brackish water. Within twelve hours of injury, his condition rapidly deteriorated with proximally- advancing erythema, edema, paresthesias and pain. Broad-spectrum antibiotics and surgical consultation were provided at a community hospital, where limited decompressive fasciotomies and debridement were performed. Wound cultures demonstrated few Gram-negative rods without identifiable speciation. Several days later, he was transferred to our tertiary care institution for surgical care of presumed Vibrio spp. necrotizing fasciitis.

The patient was afebrile and hemodynamically stable on arrival, but with significant edema of the right upper extremity extending from the distal digits to the mid-forearm. Thickened necrotic eschar involved 75% of the palm and hand dorsum, resulting in limited active range of motion to the hand and wrist. The forearm compartments remained soft and compressible. The hand was largely neurovascularly intact with sensation limited to deep pressure, and the patient reported minimal pain.

Methods: Given the suspected diagnosis of marine NSTI, repeat surgical aggressive debridement of the right hand was performed, including completion of forearm and hand fasciotomies and partial amputation of the thumb. Major neurovascular structures were intact but traumatized. The patient underwent serial debridement, subsequent revision amputation of the thumb, and soft tissue reconstruction with acellular dermal matrix. Despite aggressive operative debridement, progressive deep-tissue necrosis persisted on multiple returns to the operating room. When tissue control was finally achieved, the distal palm was reconstructed with a reverse radial forearm flap. Serial joint manipulation under anesthesia was performed to maximize postoperative range of motion.

Results: After seven surgeries, the patient engaged with aggressive and frequent hand therapy. Within six months of reconstruction, the patient demonstrated significant improvement in thumb-to-index pinch and improved MP joint motion of the grip-imperative ring and small fingers. One year later, the patient reports no pain, improved sensation, and actively enjoys activities of daily living including gardening, golfing, and fishing.

Conclusion: Early diagnosis and aggressive serial surgical intervention are essential in cases of NSTI. Culture data obtained even at the time of the first operative intervention may lead to no bacterial speciation, so NSTI cause by common marine pathogens must be treated even without culture data. Source control with aggressive surgical debridement of all compromised and non-viable tissue is critical. Staged and multidisciplinary approaches to reconstructive surgery in the hand can offer meaningful functional recovery in these devastating infections.