Keywords
snakebite - local manifestations - reconstruction - flap - distraction - Marjolin's
ulcer - case series
Introduction
Most of the snakes found in Kashmir belong to the nonvenomous Colubridae family; however,
the Levantine viper and the Himalayan pit viper are two fatally venomous snake varieties
found here.[1]
Incidence of secondary complications following snakebite ranges from 10 to 44%.[2] The wound complications can have debilitating sequelae like muscle and tendon contractures,
gangrenous and necrotic tissue, osteomyelitis, chronic wound infection, disfigurement,
and deformities, most of which may require reconstruction.[2] Local tissue necrosis is caused by direct tissue toxicity or because of ischemia
secondary to local vessel thrombosis.[3] Local tissue necrosis is more likely when the venom is trapped locally using a tourniquet.[4]
The priority in the treatment of snakebites is to manage systemic toxicity, but addressing
local effects helps to further improve the overall management and the results in such
cases.[2]
The three goals of surgical treatment of such wounds are, first, to reduce the total
venom load; second, to prevent ongoing local tissue injury; and third, to treat established
wound necrosis and long-term complications.[5]
Aims and Objectives
The aim of this study was to evaluate the clinical profile, acute, subacute, and chronic
bite site manifestations of snakebite victims and the role of a plastic surgeon in
their management.
Materials and Methods
This is a prospective single-institution case series conducted from November 2019
to December 2021 on consecutive cases in a teaching hospital.
Inclusion criteria:
-
Snakebite victims admitted under emergency medicine/pediatrics/critical care in which
plastic surgery consultation was sought for bite site manifestations.
-
Snakebite victims referred from other hospitals for reconstruction.
-
Informed consent.
Exclusion criteria:
Refusal to participate in the study.
Patient demographic characteristics and the snakebite-related information like time
and site of the bite, local bite site manifestations, features of compartment syndrome
like (paresthesia, decreased capillary refill, pain to passive motion, or decreased
pulses), length of hospitalization, surgical lesions encountered, coagulation profile,
treatment offered, and complications were recorded. Complete blood count, coagulation
profile, and liver and renal function tests were sought. Patients were followed till
December 2022.
Ethical considerations: Ethics approval was obtained from the institutional ethics review committee. Written
informed consent was obtained from the patients for the publication of the images.
This case series has been reported in line with the PROCESS Guideline.[6]
Results
Fifteen patients (10 males and 5 females) with ages ranging from 10 to 53 years (mean:
36.5 years) were included. One patient was bitten on his face while sleeping on a
cot in an open compound, while the rest of the patients were bitten while venturing
outdoors. Only eight patients (53.3%) had seen the offender snakes and identified
them as viper “Gunas.” The lower extremity was the most common site involved in nine
cases (60%) followed by the upper limb in five (33.3%) and the face in one case (6.7%).
Acute snakebite cases were primarily managed by physicians and critical care specialists
that included administration of antisnake venom (ASV) and supportive care till coagulogram
normalized (international normalized rate [INR] <1.2). Seven patients (46.7%) had
received polyvalent ASV and the time from the bite to the administration of ASV ranged
from 3 to 24 hours. Five patients (33.3%) had gone to traditional healers and 6 patients
(40%) had applied tourniquets for varying periods ranging from 1 to 3 hours before
reporting to the nearest hospital for proper care. Most of the patients (8 [53.3%])
had coagulopathy revealed by their deranged coagulograms. Surgical procedures were
performed only after coagulopathy was corrected with INR less than 1.2. The patients
underwent various surgical procedures as described in [Table 1] ([Figs. 1]
[2]
[3]
[4]
[5]
[6]).
Table 1
Snakebite site, its local manifestations, and their management
|
Sl. no.
|
Site of bite
|
Surgical pathology
|
Management
|
Time from snake bite to treatment by plastic surgeon
|
Presentation
Primary/Secondary
|
|
1.
|
Hand
|
Compartment syndrome, soft tissue necrosis middle finger
|
Fasciotomy, debridement, and groin flap
|
28 hours
|
Primary
|
|
2.
|
Face
|
Necrotizing fasciitis face and chest wall
|
Debridement, temporary tarsorrhaphy, buccal myomucosal flap, split-thickness skin
grafting, ectropion release with full-thickness grafting
|
7 days
|
Secondary
|
|
3.
|
Foot
|
Lower limb edema
|
Limb elevation, serial clinical monitoring
|
13 hours
|
Primary
|
|
4.
|
Calf
|
Lower limb edema, bite site necrosis
|
Debridement of necrotic tissue, serial clinical monitoring
|
32 hours
|
Secondary
|
|
5.
|
Thigh
|
Lower limb edema, minimal bite site necrosis
|
Limb elevation, topical antibiotic dressing, serial clinical monitoring
|
16 hours
|
Primary
|
|
6.
|
Hand (ring finger)
|
Compartment syndrome, blister, and localized necrosis ring finger
|
Upper limb fasciotomy, minimal debridement followed by skin grafting
|
18 hours
|
Secondary
|
|
7.
|
Ankle
|
Nonhealing ulcer in a post-snake bite scar (Marjolin's ulcer)
|
Below knee amputation
|
26 years
|
Secondary
|
|
8.
|
Hand (dorsum)
|
Compartment syndrome, minimal bite site necrosis
|
Fasciotomy, followed by healing by secondary intention
|
22 hours
|
Primary
|
|
9.
|
Leg
|
Lower limb edema, 15 cm2 bite site necrosis
|
Debridement, split-thickness skin grafting
|
42 hours
|
Secondary
|
|
10.
|
Forearm
|
Progressive edema
|
Limb elevation (conservative management)
|
14 hours
|
Primary
|
|
11.
|
Thigh
|
Extensive skin and subcutaneous tissue necrosis of the thigh (necrotizing fasciitis)
|
Debridement, customized negative pressure wound therapy, split-thickness skin grafting
|
10 days
|
Secondary
|
|
12.
|
Calf
|
Significant lower limb edema, 6 cm2 bite site necrosis
|
Debridement, limb elevation, topical antibiotic dressing, serial clinical monitoring
|
68 hours
|
Secondary
|
|
13.
|
Foot
|
Lower limb edema
|
Limb elevation (conservative management)
|
34 hours
|
Secondary
|
|
14.
|
Leg
|
Blister at bite site and limb edema
|
Blister debridement, limb elevation (conservative management)
|
23 hours
|
Secondary
|
|
15.
|
Hand (index finger)
|
Osteomyelitis with deformity of proximal interphalangeal joint
|
Debridement of osteomyelitic bone after distraction, cross-finger flap, and bone grafting
|
2 years
|
Secondary
|
Fig. 1 (A, B) Snakebite right ring finger. (C, D) Fasciotomy wounds. (E, F) Secondary suturing and split-thickness skin grafting of wounds.
Fig. 2 (A) Snakebite left middle finger. (B, C) Fasciotomy wounds. (D, E) Skin and soft tissue necrosis at the bite site. (F) Pedicled left groin flap in situ after debridement and Kirschner wire fixation of
the distal interphalangeal joint. (G, H, I) Groin flap well inset after detachment with the restoration of form and function.
Fig. 3 (A) Post-snakebite necrotizing fasciitis wounds after debridement. (B) Customized negative pressure wound therapy applied. (C) Split-thickness skin grafts well taken with residual intervening areas left to heal
by secondary intention.
Fig. 4 (A) Snakebite face with skin and soft tissue necrosis involving the right forehead,
periorbital area, cheek, root of nose, left infraorbital region, right supraclavicular,
suprasternal area, and upper chest. (B) Gloved finger depicting an orocutaneous fistula in the right cheek. (C) Intraoperative picture of wounds following debridement. (D) Postoperative picture after reconstruction and residual right lower lid ectropion.
Fig. 5 (A) Snakebite right calf with minimal bite site necrosis. (B) Fang marks over the right ankle with lower limb edema in a young female. (C) Marjolin's ulcer over left ankle and foot in a chronic snake bite scar.
Fig. 6 (A, B) Chronic snakebite with deformity of left index finger. (C) X-ray revealing telescoping at proximal interphalangeal joint and osteomyelitis
of the adjoining phalanges. (D) Uniplanar mini-distractor in situ after completion of distraction. (E) X-ray picture postdistraction. (F) Cross-finger flap from middle finger following debridement of osteomyelitic bone.
(G, H) Flap well inset following bone grafting; restoring finger length and function.
Majority of the patients identified delay in treatment and timely referral to multiple
reasons like lack of transport, lack of proper training of the local doctor in specialized
wound care, nonavailability of a plastic surgeon in their nearby peripheral hospital,
poor socioeconomic status, and failure to identify the gravity of the local complication
in time.
Hospitalization ranged from 5 to 25 days. All patients adhered well to postoperative
physiotherapy advices. No major complications were encountered. Minor complications
included wound infection in two cases, which was managed conservatively with culture-specific
antibiotics and dressings, besides conspicuous scarring at the bite site in one case.
All the reconstructed wounds were stable at follow-up and patients returned to their
normal routine by 2 to 3 months.
Discussion
Socioeconomic status and a lack of access to healthcare preclude timely treatment
of snakebites in resource-limited countries resulting in higher rates of secondary
complications as compared with developed countries necessitating even more the need
for a plastic surgeon for management of the resulting sequelae.[2] Overall, the exact incidence of snakebites requiring some kind of formal reconstruction
is unknown. In the large majority of snake envenomation cases, the services of a plastic
surgeon are sought for assessment and management of the local complications of the
bites for restoration of form and function.[2]
[4]
The first reported case of envenoming by the Levantine viper in India was a 33-year-old
male soldier.[3] Most of the snakebite victims reported in the literature are children.[4] However, in the study of 158 patients by Kim et al, the authors encountered patients
of all age groups with a majority of the patients in 40 to 70 year groups (102 males
vs. 56 females).[7] Young males are affected more, being the predominant workforce outdoors for soldiering
duties, farming, and outdoor activity and thus vulnerable to this occupational hazard.[8]
The most common area reported in the literature is the lower limb.[1]
[2]
[4] Besides this, head and neck,[1] upper limb,[3] penis,[9] and scrotum[10] have been reported as other bite sites. Feet and legs are the most accessible sites
while working outdoors to any creeper for inflicting a bite, thus explaining the highest
incidence of involvement.
Though their use is discouraged, a big number of snakebite victims still apply proximal
tourniquets.[1]
[2] Antivenin therapy has been reported to be more effective in decreasing the incidence
of local complications and the need for surgical interventions.[1]
[2]
[5]
Three patients (20%) with compartment syndrome following a bite on the right ring
finger, left middle finger, and right-hand dorsum were identified based on clinical
signs and symptoms and urgent fasciotomy was performed. All of them had applied tourniquets
in the prehospital period. It is not necessarily recommended to measure intracranial
pressure when the diagnosis is clinically evident.[11] Need for fasciotomies in snakebite victims, although rare, has still been performed
wherever indicated more commonly in upper limbs where the venom is usually deposited
deeper, thus leading to severe edema and resultant muscle ischemia in tight compartments.[7]
All three patients who underwent fasciotomy had used torniquet. Use of torniquet and
delay in timely referral reported by the patients lead to such complications. Training
of doctors working in peripheral hospitals in wound care, timely referral to centers
offering plastic surgical services, and avoidance of torniquet use can reduce the
incidence of such sequelae.
An algorithmic approach to the prevention of unnecessary fasciotomy in extremity snakebite
has been proposed by Türkmen and Temel.[12] However, there are a few limitations of this study; first, the threshold pressure
set is higher than conventional 30 mm Hg, second, the pressure readings are to be
repeated thrice after every 2 hours making it 6 hours before a decision for fasciotomy
is taken as compared with the conventional practice of a single reading.[2] We feel the high threshold and need for repeated readings leading to delayed fasciotomy
could in all probability lead to ischemic changes and resultant sequelae in these
cases. Third, snakebites are more common in developing countries where the equipment
for compartment pressure measurement is not available commonly thus limiting the applicability
of this protocol where it is required most. Fourth, since long term follow-up is missing,
the number of patients out of the remaining 37 in whom fasciotomy was not done and
from the 3 in whom fasciotomy was performed after delay of 6 hours from the first
recording, which might have landed up with Volkmann's ischemic contractures and other
sequelae are not known.
The patient with a facial snakebite had extensive necrosis involving the face and
chest wall. After having been bitten on his face, the venom must have trickled down
the tissue planes in his neck to the upper chest wall, leading to tissue necrosis
involving the face, lower part of the neck, and upper chest with spared intervening
areas in the neck. Snakebite envenomation of the face usually occurs in children or
agricultural workers.[13] Envenomation of the face leads to tissue necrosis, and deformity necessitating reconstruction
and may even lead to death if not diagnosed and managed promptly.[14]
In our study, we encountered one case of Marjolin's ulcer in snakebite scar. Marjolin's
ulcer developing in snakebite scar is very rare. One such case has been reported by
Smith et al.[15]
The patient with osteomyelitis, dislocation of proximal interphalangeal joint and
deformity of index finger following snakebite 2 years back was managed by staged reconstruction
including debridement of the wound and osteomyelitic bone, distraction, cross-finger
flap, and bone grafting. The finger was salvaged and he could use it reasonably well
in his day-to-day activities. Osteonecrosis and dislocation of small joints of the
fingers post-envenomation and their management by debridement and cross-finger flaps
have been reported in rare cases.[2] In the study by Huang et al regarding hand deformities in snakebite victims, seven
patients required skin grafts or flap cover, while one patient had proximal interphalangeal
joint destruction and underwent ray amputation.[16]
The patient who was bitten on the middle finger progressed to soft tissue gangrene
even after a timely fasciotomy. Debridement and reconstruction with an ipsilateral
groin flap were done for the restoration of acceptable function, though the interphalangeal
joints were stiff at follow-up. Groin flaps have been used for soft tissue reconstruction
of hands in snakebite victims by Russel et al with good results.[2]
The plastic surgeon should be well versed in the acute and long-term management of
such complex wounds, and the nuances involved in such reconstruction, allowing patients
to regain their normal life. Disagreement and controversy regarding fasciotomy post-envenomation
can result in severe consequences if true compartment syndrome is not acted upon in
a timely manner. Amputations are most common in envenomation to the digits or toes.
Reconstruction post-envenomation should be planned as any other soft-tissue defect,
paying special attention to proper debridement. Envenomation of the lower extremity
can be difficult for reconstruction because of paucity of tissues in the foot and
lack of robust blood supply to utilize for local grafts and flaps. Envenomation to
the face can cause tissue necrosis and deformity, making reconstruction essential
but difficult. Envenomation of hand often requires a graft or flap to allow for the
return of form and function. Role of free flaps should always be kept in mind in cases
with paucity of locoregional options.[2]
Strength of the study: Uncommon and rarely reported bite site complications and their management.
Weaknesses of the study: Limited sample size.
Directions for future research: Multicenter studies with larger sample sizes for developing standardized treatment
recommendations.
Conclusions
Snakebite victims should be referred promptly to the proper center, to avoid delay
in treatment and possible complications. Awareness campaign regarding avoidance of
torniquet should be generated. Plastic surgeons play an important role in the management
of acute bite site effects and sequelae for restoration of form and function and should
be an integral part of the core team involved in the management of snakebite victims
and their rehabilitation.
