Statement of Clinical Problem: An 80 year old male presented to the emergency room with a puncture wound of the dorsal aspect of right hand from a live crab. Wound infection progressed rapidly within 24 hours resulting in septic shock and metabolic acidosis. The tissue necrosis migrated anteriorly, proximally and distally involving the entire forearm and hand. Tendons were exposed in 4 areas. Comorbidities included: hypertension, coronary artery disease, diabetes, coronary artery bypass graft and right upper lobe lobectomy.

Description of Past Management: Moist saline dressings were applied for 24 hours status post fasciotomy.

Clinical Approaches: Patient had emergency fasciotomy and extensive debridement on 7/23/06. General surgery, orthopaedic surgery, infectious disease, hand therapy, WOC nurse, intensive care specialist, and plastic surgery created the initial team providing care for this complex patient. Wound care was consulted for assessment and treatment recommendations. Silicone sheeting and hydrogel were used initially. Tissue necrosis was too extensive to place negative pressure wound therapy. One week post-sepsis, NPWT was placed in preparation for skin graft on 8/9/06. Donor site was 10% of total body surface area. A standard foam hand dressing was found to be inadequate for the wound configuration requiring creation of a custom made foam dressing. Silicone wound dressing and wound emulsion dressing were used under the NPWT dressing to facilitate continued debridement for graft site preparation. Active Hand Therapy began three weeks after skin graft and continues.

Patient Outcomes: Patient's right arm and hand healed in three months. Hand therapy continues to optimize gross and fine motor function. To date patient has been able to resume his part time occupation as a barber.

Conclusions: Patient survival, limb salvage, wound healing and function were maximized as a result of a highly integrated team approach.