Gras, S

English

MSF Field Research

Snakebite on the hand: lessons from two clinical cases illustrating 
difficulties of surgical indication
Gras S (1), Plantefève G (2), Baud F (1), Chippaux JP (3, 4)
(1) Department of Medicine, Doctors Without Borders, Paris, France; (2) Polyvalent Reanimation Service, Victor Dupouy 
Hospital Center, Argenteuil, France; (3) Center for the Study and Research of Malaria Associated with Pregnancy and 
Childhood (Cerpage), Cotonou, Benin; (4) Institute of Research for Development (IRD – UMR 216 “Mother and child facing 
tropical diseases”), Cotonou, Benin.
Abstract: Snakebite is a particularly important health problem in rural areas of tropical regions. A large 
number of victims survive with permanent physical sequelae due to local tissue necrosis. However, necrosis 
may be associated with compartment syndrome especially when the bite is on the hands or feet. Herein, 
we describe two cases reported at a rural district hospital in Central African Republic. The present study 
suggests that active multidisciplinary management may improve patient prognosis while evidencing how 
difficult it is to decide on surgical intervention.
Key words: snakebite, Africa, compartment syndrome, surgery.
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The Journal of Venomous Animals and Toxins including Tropical Diseases 
ISSN 1678-9199  |  2012  |  volume 18  |  issue 4  |  pages 467-477
INTRODUCTION
Since 2009, snakebites have been considered 
a neglected disease by the World Health 
Organization (WHO) (1). In sub-Saharan Africa, 
recent estimates suggest that about 1 million bites 
by venomous snake occurred, with 100,000 to 
500,000 cases of envenomations and up to 30,000 
deaths per year (2, 3). Such figures indicate that 
snakebites comprise a particularly important 
health problem in rural areas of tropical regions. 
Populations in these regions face high morbidity 
and mortality due to the poor access to health 
services. Although numerous victims survive, 
they have permanent physical sequelae due 
to local tissue necrosis which may result in 
psychological problems as well. The economic 
impact of their disability is also considerable.
Echis is one of the most frequent and 
dangerous snakes in West Africa and sub-Saharan 
countries. It is a small sand-colored snake that 
belongs to Viperidae family. Its venom contains 
mainly different proteins and enzymes such as 
metalloproteases that provokes edema, blisters, 
necrosis and hemorrhagic syndrome. The toxins 
may also induce compartment syndrome because 
of deep muscle edema. Echis bites require support 
of a multidisciplinary team and demand specific 
treatment (antivenom) – in order to stop the 
hemorrhagic process – and non-specific measures 
– in case of necessary surgeries, dressings, or 
skin grafts. Usually, such complications are time-
consuming and difficult to be treated. However, as 
suggested in the two cases reported in the present 
study, multidisciplinary approach can actually 
change the patient prognosis.
The two cases presented in a district rural 
hospital, in Paoua, Ouham-Pende Province, 
Central African Republic. The hospital was 
supported by Doctors Without Borders who 
provided equipments and human resources. This 
explains why antivenom and surgery were always Gras S, et al. Surgical treatment of snakebite on the hand
J Venom Anim Toxins incl Trop Dis  |  2012  |  volume 18  |  issue 4  468
Figure 1. Initial examination showed that the right hand and forearm were swollen.
Figure 2. Initial perioperative observations.Gras S, et al. Surgical treatment of snakebite on the hand
J Venom Anim Toxins incl Trop Dis  |  2012  |  volume 18  |  issue 4  469
Figure 3. Wound cleaning.
Figure 4.  Skin graft.Gras S, et al. Surgical treatment of snakebite on the hand
J Venom Anim Toxins incl Trop Dis  |  2012  |  volume 18  |  issue 4  470
Figure 5. Final result.
available, in spite of their financial cost. In the 
hospital, a clinical study on snakebites was being 
carried out due to their high incidence in that area. 
From January 2009 to March 2011, 842 patients 
with snakebite history had been admitted, of 
which 825 were included in the study. We noticed 
that 25% of victims were bitten on their hand 
and 71% on the foot. The most frequent affected 
limbs in the region were similar in other parts of 
Africa and Asia (3-6). Out of the 825 patients, 
68 (10.6%) showed local complications, and 29 
(3.5%) of them required surgery.
CASE REPORT 1
A 18-month-old boy was bitten on his right 
hand early on the morning, when he was playing 
outside, on the floor, just in front of his parent’s 
house. He presented in our hospital less than one 
hour after the bite. At initial clinical examination, 
there was no bleeding, no neurological 
abnormalities but the hand and the right forearm 
were swollen and very painful (Figure 1). Because 
of the extensive swelling, the child immediately 
received the first dose of antivenom (FAV-
Afrique®) in addition to the usual treatment 
including tetanus toxoid, tetanus vaccination, 
amoxicillin, acetaminophen, and ibuprofen.
Despite of the rapid first aid, the swelling was 
still increasing and the edema extended to the 
limb. He received a 2nd dose of antivenom at day 
1, but without any notorious effect on the edema. 
The edema was evaluated and did not present any 
clinical bleeding or neurological signs. On Day 2, 
the swelling was still in progress and extended to 
the hemithorax. Therefore, he received a 3rd dose 
of antivenom. Afterward, the swelling stopped, 
but the edema did not diminish.
Because of the extended edema with 
blisters and a possible associated compartment 
syndrome, the child underwent surgery at Day 4 
for debridement and exploration. Perioperative Gras S, et al. Surgical treatment of snakebite on the hand
J Venom Anim Toxins incl Trop Dis  |  2012  |  volume 18  |  issue 4  471
Figure 6. Initial aspect of the left hand.
Figure 7. Initial aspect of the left hand, second image.Gras S, et al. Surgical treatment of snakebite on the hand
J Venom Anim Toxins incl Trop Dis  |  2012  |  volume 18  |  issue 4  472
Figure 8. Fasciotomy.
Figure 9. Necrosis aspect.Gras S, et al. Surgical treatment of snakebite on the hand
J Venom Anim Toxins incl Trop Dis  |  2012  |  volume 18  |  issue 4  473
observations showed massive subcutaneous 
necrosis reaching the entire arm, from fingers 
to the shoulder. But there was no evidence of 
compartment syndrome and muscular necrosis 
(Figure 2).
Because of the large wound due to skin 
debridement, the patient received a 7-day 
prophylactic antibiotic therapy using amoxicillin 
and clavulanic acid. He went back to the operating 
room every 2 or 3 days for cleaning the wound and 
changing the dressing under general anesthesia 
(Figure 3). After 11 surgical interventions and 
33 days at the hospital, the child’s arm was finally 
skin grafted with a good result (Figure 4), which 
allowed doing the dressing without anesthesia, 
at the outpatient department. The final result of 
the procedures was aesthetically and functionally 
considered successful because there was no deficit 
except the 3rd finger extensor (Figure 5). 
CASE REPORT 2 
A 13-year-old boy presented to our hospital 
because of snakebite on his left hand that had 
occurred six hours before. He was hunting bush 
rats, and when he put put his hand in a hole, 
he was bitten. On arrival he presented clinical 
hemorrhagic syndrome with gingival bleeding 
and an edema extending to his back and shoulder. 
Laboratory tests carried out included WBCT20 
Figure 10. Finger amputation and necrosis.Gras S, et al. Surgical treatment of snakebite on the hand
J Venom Anim Toxins incl Trop Dis  |  2012  |  volume 18  |  issue 4  474
(whole blood clotting test, 20 minutes) and the 
patient had incoagulable blood. Just after his 
admission, he received the first dose of antivenom 
(FAV-Afrique®) in association with the usual 
non-specific treatment (tetanus toxoid, tetanus 
vaccination, amoxicillin, acetaminophen, and 
ibuprofen). 
Due to persistent swelling (the edema 
reached the thorax) he received a second dose 
of antivenom six hours after the first. Then, the 
edema stopped increasing and there was no more 
clinical bleeding. Although the edema stopped 
growing, the hand still had a worrying aspect. 
The skin was very hard; nails were white, without 
any evidence of blood circulation; and physical 
examination showed sensory and movement 
deficits (Figures 6 and 7). The patient underwent 
surgery on Day 1. Perioperative observations 
showed hand compartment syndrome and deep 
hematomas. Fasciotomy was performed and 
muscles below were black with almost no blood 
flow (Figure 8). 
The patient went back to the operating room 
every 2 or 3 days in order to clean the wound 
and remove necrosis. The local evolution was 
unfavorable. Necrosis extended to the whole hand 
(Figure 9). Finger amputations were necessary 
(Figures 10, 11, 12).
After eight surgeries, his condition finally 
improved and the clean wound allowed a skin 
graft (Figure 13). 
Unfortunately, the patient ‘escaped’ at Day 
25 of hospitalization, before we could manage 
the skin graft. We did not have news from him. 
Unfortunately, the habit of being outside, in the 
bush, with such a wound and no sanitary supplies 
is of poor prognosis.
DISCUSSION
The two cases reported herein represent a 
relatively common situation in Africa and Asia 
(7-11). Children are particularly vulnerable 
when seeking food in rodent burrows or playing 
with what they find without understanding the 
hazard. It is often difficult to identify the species 
responsible for biting. Echis ocellatus is both 
the most common and the one for which the 
circumstances of the bite matched best. But we 
cannot exclude, particularly in the first case, a bite 
from Bitis arietans regarding the extension of the 
edema and the absence of bleeding.
Most of the literature is focused on snakebite 
mortality. However, many patients survive, and 
an elevated proportion of them suffer from local 
complications and sequelae. These may be due 
to the direct toxicological action of the venom 
associated or not with iatrogenic manipulations 
(12). Some enzymes induce tissue destruction, 
resulting in different levels of necrosis. Edema 
may compress blood vessels and prevent the 
vascularization of the extremities (compartment 
syndrome), which is exacerbated by vascular 
lesions caused by hemorragins, inappropriate 
treatments (tourniquet) or severe anemia caused 
by bleedings. 
The outcome of the two reported cases 
may appear very similar (a necrosis leading to 
amputation), but the diagnosis and management 
are of course very different. A meta-analysis in 
2011 reported an incidence of 5.5% of sequelae 
and 3% of amputations (8). In our own study, 
this rate is lower (0.5% of amputation), probably 
because of our active support (as previously 
Figure 11. Finger amputation and necrosis, second 
picture.Gras S, et al. Surgical treatment of snakebite on the hand
J Venom Anim Toxins incl Trop Dis  |  2012  |  volume 18  |  issue 4  475
mentioned). In rural tropics, decreasing and even 
avoiding physical sequelae, for an agricultural 
population is absolutely necessary, because 
physical strength means survival.
For a while, excision of necrotic tissue – and 
even amputation of the limb – was the heroic 
treatment of snakebite (4, 6, 12). This strategy 
was justifiable when antivenoms lacked safety 
and were less effective, as well as resuscitation 
and surgery, than nowadays. The effectiveness 
of fasciotomy is not yet well demonstrated 
and more conservative treatments are now 
available (4, 10, 11, 13). On one hand, there is 
evidence that modern antivenoms both limit 
the spread of necrosis by inhibiting protease 
activity and reduce edema, leading to decreased 
risk of compartment syndrome (14, 15). On the 
other hand, symptomatic treatment (diuretics, 
mannitol) were also shown to be effective (5, 15).
As shown in the two case reports, worsening 
of a bite on the hand may develop rapidly. In 
the second case, despite the use of antivenom, 
compartment syndrome appeared within a 
few hours. And even an early surgery cannot 
avoid necrosis onset. This leads to a question: 
what are the indication and advantages of early 
fasciotomy in the management of compartment 
syndrome? Edema, especially if limited, is not 
enough to justify a fasciotomy. Ribeiro et al. (16) 
attempted to determine the risk factors for local 
complications. Bites on extremities, especially 
the hand, the size of the snake – which suggests a 
connection with the amount of venom (but also 
with the fang size because deep bites induce more 
Figure 12. Finger amputation and necrosis, third picture.Gras S, et al. Surgical treatment of snakebite on the hand
J Venom Anim Toxins incl Trop Dis  |  2012  |  volume 18  |  issue 4  476
severe local complication) – and the severity of 
envenomation (associated with bleeding) may be 
considered risk factors (17). However, fortunately, 
most cases of envenomation are not complicated 
by compartment syndrome or sequelae (7-9, 12, 
13). In addition, infectious and hemorrhagic 
complications should be taken into consideration. 
Some authors report a high level of 
hemorrhagic and infectious complications after 
early surgery (7). The indication of fasciotomy 
should not be based solely on clinical symptoms 
(edema and weakening or abolition of distal 
pulses). Measurements of intracompartmental 
pressure were described in 1975 (18), but are still 
rarely used in developing countries although they 
showed high interest (19-21). From experimental 
data, Garfin et al. (17) showed that the pressure 
measurement in deep compartments were more 
informative and relevant than the measurement 
of subcutaneous pressure. The latter varies little 
and within narrow limits, while measurement 
of deep intracompartmental pressure is likely 
to evaluate more efficiently the severity of 
ischemia. Several criteria have been defined, but 
it seems that the best estimate is given by the 
difference between the diastolic pressure and 
the intracompartmental pressure, which should 
remain less than 30 mmHg (15, 21). However, 
other clinical and biological parameters could be 
useful, such as oxymeters and ultrasonography.
To the best of our knowledge, conservative 
attitude (armed expectancy) appears to be the 
best approach for the management of local 
complications due to viper bite whether necrosis 
is due to tissue destruction by venom enzymes 
or distal ischemia-related compartmental 
syndrome. It is not easy to decide whether 
fasciotomy is indicated or not. Decision should 
also take into consideration local environment, 
equipment, and facilities. As shown in the two 
case reports, surgery, even in remote areas may 
be associated with good results, but it requires 
high investment from the medical team and the 
patient. It never comprises a one-shot surgery. 
However, if one can avoid iterative surgery, the 
benefit for patient could be very important. The 
main problem remains the surgical indication 
Figure 13. Clean aspect of the hand, after eight surgeries.Gras S, et al. Surgical treatment of snakebite on the hand
J Venom Anim Toxins incl Trop Dis  |  2012  |  volume 18  |  issue 4  477
based on a multidisciplinary approach and not 
just on a clinical consideration.
COPYRIGHT 
© CEVAP 2012
SUBMISSION STATUS
Received: September 19, 2012.
Accepted: October 23, 2012.
Abstract published online: October 29, 2012.
Full paper published online: November 30, 2012.
CONFLICTS OF INTEREST
The authors declare no conflicts of interest.
FINANCIAL SOURCE
The study was supported by Médecins Sans 
Frontières (French NGO “Doctors Without 
Borders”).
ETHICS COMMITTEE APPROVAL 
The present descriptive study based on medical 
records of Paoua Hospital was approved by CAR 
Ministry of Health. 
CORRESPONDENCE TO
Séverine Gras, Département Médical, Médecins 
Sans Frontières, 8 rue Saint Sabin, 75011 Paris, 
France. Email: severine.gras@gmail.com. 
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Amputation and disability following snakebite in Nigeria. Trop Doctor.

Complications of Bothrops, Porthidium, and Bothriechis snakebites in Colombia. A clinical and epidemiological study of 39 cases attended in a university hospital.

Direct intracompartmental pressure measurement in the management of snakebites in children.

Estimate of the burden of snakebites in sub-Saharan Africa: a meta-analytic approach.

Hand deformities in patients with snakebite. Plastic and reconstructive surgery.

Is there a role for fasciotomy in Crotalinae envenomations in North America? Clin toxicol (Phila).

Les serpents d’Afrique occidentale et centrale. Paris: IRD Éditions;

Local complications of snake bites (author’s transl). Med Trop.

Morsure par vipère Bitis arietans au Sénégal, intérêt de la mesure de pression intracompartimentale [Envenomation by the African puff adder (Bitis arietans): value of intracompartmental pressure measurement].

Organization. Neglected tropical disease: snakebites [Internet]. WHO: Geneva;

Prognostic factors for local necrosis in Bothrops jararaca (Brazilian pit viper) bites. Trans R Soc Trop Med Hyg.

Raised compartmental pressure in children: a basis for management.

Rattlesnake bites and surgical decompression: results using a laboratory model.

Resolution of compartment syndrome after rattlesnake envenomation utilizing non-invasive measures.

Snakebite in Africa: Current situation and urgent needs. In:

Surgery in management of snake envenomation in children.

Surgery should not be used as a first line treatment.

Surgical implications of snakebites.

The effect of antivenin on intramuscular pressure elevations induced by rattlesnake venom.

The global burden of snakebite: a literature analysis and modelling based on regional estimates of envenoming and deaths. PLoS medicine.

Tissue pressure measurements as a determinant for the need of fasciotomy. Clin Orthop Relat Res.

Snakebite on the hand: Lessons from two clinical cases illustrating difficulties of Surgical Indication

Snakebite on the hand: Lessons from two clinical cases illustrating difficulties of Surgical Indication

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