have a history of skin injury, 25% have experi­enced blunt trauma, and 70% have at least one chronic disease. Half of all cases of necrotizing fasciitis occur in one lower limb and 30% in one upper limb.

NF is a rapidly progressive and destructive bacte­rial infection affecting supercial and deep soft tissues, including the skin, subcutaneous tissue, fascia, and muscle. Within hours to days, the infec­tion can progress from a seemingly benign skin lesion to a highly mortal condition (Fig. 44.1). Many clinical studies have reported that rapid and deep enough surgical debridement of infected tis­sue within 12–24h from the onset of the original clinical manifestation is crucial for saving lives [4]. The bacterial infection spreads along the fas­cial and peri-ligamental planes, and excision of adjacent muscles or deep tissue is required. The fascia, with its loose brous connective tissue and neurovascular structures, provides a little anatomic barrier against the dissemination of pathogens. GAS proliferates in sterile sites and rapidly attacks acute inammatory cells, resulting in severe tissue damage, which is compounded by potent prote­ases and degenerative virulent factors expressed by invading GAS and host-released polymorpho­nuclear (PMN) leukocytes (Fig.44.2).

which quickly evolve into bleeding bullae, indi­cating that deep blood vessels in the fascia or muscle compartments have become occluded. The presence of bullae is therefore crucial for the clinical diagnosis of NF.Ludwig’s angina (in the submandibular space) and Fournier’s gangrene (in the scrotum, penis, or vulva) are variants of NF and often exhibit an explosive and aggressive clinical course.

Early and wide and deep enough surgical debride­ment is the mainstay treatment for NF and leads to better mortality compared to those who under­went surgery with a delay of a few hours [8]. When NF is suspected, the patient should be brought to the operating room for extensive sur­gical debridement. All infected tissue should be completely removed until there is no further evi­dence of infection. If further debridement is required, the patient should be returned to the operating room immediately. In this context, the use of articial dermis after debridement is use­ful because it does not result in the loss of the patient’s own tissue and makes it easier for “second- look” surgery or secondary reconstruc­tion [9] (Fig.44.3).

Skin necrosis is a frequent complication in the management of traumatized extremity, particu­larly in the case of open fracture.