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.
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
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 )
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
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.