This document discusses the case of a 39-year-old female with diabetes and hypertension who presented with blackening of fingers following minor trauma. On examination, her fingers showed dry gangrene. Investigations revealed poorly controlled diabetes and hyperlipidemia. She was started on antibiotics and other medications. Orthopedics recommended amputation, but it was initially postponed. The discussion summarizes the approach to evaluating digital ischemia, including risk factors, examination findings, investigations and underlying pathologies like vessel abnormalities, hypercoagulable states, embolism and thrombosis.

1. CASE DISCUSSION
DR SUBHASHIS SHARMA
MODERATED BY :
DR PRAVEEN MALIK
DR MUSHTAQ AHMAD

2. HISTORY
 Bala,39 year old married female resident of Madangiri,New Delhi presented with
blackening of the distal phalanx of little finger and at the tip of the ring finger of
right hand following a trauma against the door[mild in nature] 2 weeks back.
 Initially she ignored it but with progressive blackening and increasing pain she
came to OPD of HAHC HOSPITAL.
 The lady is a K/C/O DM TYPE 2 for 14 years on OHA irregularl,taking treatment
only during some illness whenever RBS is high.
 She is also recently diagnosed hypertensive.
 H/O cellulitis(resolving) over left tibial shin
 H/O peeling of skin over hands during washing clothes and utensils since 10
years?contact dermatitis
 No H/O abortion

3. On Examination
 afebrile
 affected part was cold, black, tender and dry.
 All the peripheral pulses were palpable
 B.P measured in 4 limbs[RA 160/100,LA 148/96.RL 162/96,LL 154/98] with
pulse rate 88
 Skin is doughy with multiple striae over trunk and proximal limbs[B/L]
 Malar rash for 8 years after delivery
 Oral ulcers

4. Investigations
 ESR 28,Hb 13.2, DLC [N: 65,L: 23,E:10]rest is WNL
 KFT: Albumin 3
 LFT:WNL
 URINE R/M: sugar ++++,albumin trace,pus cell 2/3
 USG DOPPLER RIGHT UPPER LIMB[arterial]:NORMAL STUDY,reviewed twice in the
dept.of radiology
 X-RAY right hand AP/OBLIQUE:loss of interphalangeal joint space of ring finger
with suspicious subluxation.there is flexion of this joint seen on both views ?
Deformity.
lucencies are seen in the soft tissue on volar aspect of distal phalanx of little
finger.
 CXR PA VIEW:right CP angle is blunted?pleural thickening,/ pleual effusion.left cp
angle is clear

5. CONT…..
 ANA-IFA- NEGATIVE
 RA FACTOR –NEGATIVE
 CRP-POSITIVE
 S.TSH-1.20
 BS PP-199
 HBA1C-10.1%
 LIPID PROFILE-TCHOL-213,TG-338,HDL-34,LDL-111,VLDL-68

6. TREATMENT GIVEN :
1. INJ MEROPENEM 1 gm I/V B.D
2. INJ.LANTUS 16 U S/C HS,
3. INJ HIR 6 U S/C+SLIDING SCALE TDS
4. T.DALACIN C 300 mg BD
5. T.TRENTAL 400 mg tds
6. INJ.TRAMADOL 100 mg IN 100 ML OF NS I/V TDS
7. T.ECOSPRIN AV 75/10 HS

7. REFERENCES
1. SKIN REFERENCE
IMPRESSION
 Dry gangrene of digits
 Leg shows crusted plaque s/o infected eczematous dermatitis
 Tx adviced: cosvate g cream,surgery opinion for the gangrene

8. 2. SURGERY REFERENCE
IMPRESSION
1. At present amputation is not advised( line of demarcation still not well
established special at the palmar surface)
2. Consider starting heparin
3. Review in OPD for amputation

9. ORTHOPEDIC REFERENCE
IMPRESSION
1. Dry gangrene present in rt little finger extending upto PIP joint and rt ring
finger extending below PIP joint
2. Sensation absent over gangrenous part
3. Hyperasthesia present proximal to gangrenous part
ADVICE
amputation of rt little and ring finger
later on postponded(?vascular cause….discolorisation progressive )

15. THANK YOU

16. Protocol
Clinical Details
 History of trauma,infection,drug abuse,exposure to drugs,chemicals,or
physical agents
 H/O surgical operation
 Any previous thrombosis
Look for predisposing conditions
Family H/O thrombosis or predisposing factors
Look for sources of embolism

17. Cont…….
 Pre disposing factors
 Myeloproliferative Disorder
H/O headache,dizziness,visual disturbances,tinnuitis,TIA/CVA/CAD
 Hypoxic states
 Hb disorders and cardio pulmonary disorders
 Vasculitis and APS
H/O suggestive multi organ or obstructive complications
 SLE,RA,Systemic Sclerosis,Sjogren’s syndrome

18. EXAMINE AND ASSESS
 LOCAL
 :6 P’s[pallor,pain,paraesthesia,pulselessness,poikilothermia,paralysis.
 Inducing Raynaud’s phenomenon
 Venous refilling time
 Venous guttering capillary refilling
 Signs of chronic ischaemia
 gangrene

19. Cont…
 ARTERIAL PULSES
 Absent or decreased pulse
 pulses Proximal aneurysm
 Tender on palpation - Embolus
 Lower limb : Systolic pressure at ankle and toe,
 Ankle-brachial index,
 Claudication distribution
 Upper limb : Adson’s test,
 Allen’s test

20. CONT…
 GENERAL
 Plethoric face, malar flush, conjunctival congestion
 Erythromelalgia, acral cyanosis, Raynaud’s, petechiae, photosensitivity,
arthritis,
 nodules/papules, lichen planus, pruritus, digital ulcers/gangrene

21. CONT
 SYSTEMIC
 Exclude respiratory, cardiac diseases, rheumatic heart disease
 Cerebrovascular accident, coronary artery disease
 Tumours : Ovarian, cerebellar
 Splenomegaly
 Serositis

22. INVESTIGATIONS
 Blood tests
 CBC, Hb electrophoresis, coagulation profile/factors, viscosity
 Total proteins and electrophoresis, albumin/globulins, uric acid,
calcium,
 phosphorus, liver and kidney functions.
 Serology - Rheumatoid factor, lupus anticoagulant, anti-cardiolipin,
ANA, HCV,
 VDRL
 Arterial O2 saturation

23. CONT….
 Imaging studies
 X-ray chest, USG abdomen, CT cranium, peripheral arterial doppler
 ECG, echocardiogram
 Other
 Pulmonary function tests
 Bone-marrow study
 Biopsies as required
 Special tests
 Red cell mass and plasma volume
 Erythropoietin level, independent colony characteristics

24. PATHOLOGIES AND DISEASE STATES
 VESSEL WALL: atherosclerosis , fibromuscular dysplasia,
homocystinaemia,vasculitis
 RHEOLOGICAL: Hyperviscosity states, myeloproliferative disorders
 PLATELETS AND COAGULATION: Familial defects in coagulation proteins,
dysfibrinogenaemia anticoagulants/fibrinolytic defects
 EMBOLISM: Cardiac in 75 -94% cases, proximal arterial aneurysm, paradoxical,
aortic
 atherosclerosis
 Angiography
 Infection
 THROMBOSIS :Atherosclerosis, arterial reconstruction, injury/catheter
 Aneurysmal disease, dissection
 Hypercoagulable and haematological states
 Vasculitis
 TRAUMA OR PHYSICAL: Frostbite, vibration, drugs

25. EMBOLISM THROMBOSIS TRAUMA
UPPER LIMB ++ RARE +
LOWER LIMB ++++ +
+
MECHANISMS OF DIGITAL ISCHEMIA
Note : In general, in the absence of trauma, embolism
or thrombosis could be responsible. Thrombosis
is an uncommon cause for such involvement in
upper limbs.