Beyond the Break: Radiologic Diagnosis and Outcomes of Necrotizing Fasciitis Complicating Orthopedic Fractures

Abstract

Necrotizing fasciitis (NF) is a rapidly progressive infection with high mortality. When NF complicates orthopedic fractures, early recognition is particularly challenging because swelling, erythema, and pain may be misattributed to trauma or postoperative changes. A systematic review was conducted using PubMed, Embase, Scopus, and Cochrane databases up to June 2025 according to Preferred Reporting Items for Systematic reviews and Meta-Analyses 2020 guidelines. Eligible studies included human patients with orthopedic fractures complicated by NF in whom radiologic evaluation and clinical outcomes were reported. Risk of bias was assessed using the Joanna Briggs Institute checklist for case reports. Six studies were included, comprising six individual patients with fracture-associated NF. Radiologic evaluation revealed that plain radiographs occasionally demonstrated subcutaneous gas, while CT consistently identified fascial gas, edema, and fluid tracking. MRI was most sensitive for detecting fascial necrosis, particularly in cases under immobilization casts. Clinical outcomes were poor: four patients died, one underwent limb amputation with subsequent death, and one achieved limb salvage with fracture union. Diabetes, ischemia, and virulent pathogens (e.g., Aeromonas hydrophila) were major contributors to adverse prognosis. Reporting of systemic complications, including renal dysfunction, was limited despite their recognized prognostic value. Fracture-associated NF is exceedingly rare but carries devastating outcomes, with mortality in the majority of reported cases. CT and MRI play a critical adjunctive role in diagnosis, but cannot replace urgent surgical exploration. Standardized reporting of systemic complications, especially acute kidney injury, is needed. Multicenter registries are essential to establish more robust diagnostic and prognostic frameworks.