Approach to digital gangrene

APPROACH TO DIGITAL GANGRENE

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

7. REFERENCES 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 A t present amputation is not advised( line of demarcation still not well established special at the palmar surface) Consider starting heparin Review in OPD for amputation

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

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11. P rotocol 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

12. 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

13. 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

14. 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

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

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

17. 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

18. 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

19. PATHOLOGIES AND DISEASE STATES VESSEL WALL : atherosclerosis , fibromuscular dysplasia, homocystinaemia,vasculitis RHEOLOGICAL : Hyperviscosity states, myeloproliferative disorders PLATELETS AND C OAGULATION : 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

20. 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.