Necrosis in the neuropathic foot

In the neuropathic foot, the first presentation of necrosis is almost invariably of wet necrosis, and this is caused when infection complicates an ulcer, leading to a septic arteritis of the digital and small arteries of the foot. The walls of these arteries are infiltrated by polymorphonuclear leukocytes leading to occlusion of the lumen by septic thrombus. This leads to the so-called 'diabetic gangrene' where a toe become blue and subsequently black and necrosed, while a few centimetres proximally a bounding pedal pulse can often be palpated. It is this presentation which probably gave rise to the myth of diabetic gangrene being caused by 'small vessel disease'. Sometimes the portal of entry for the infection which damages the digital arteries is on the same toe, but it may be proximal and is sometimes several centimetres away from the affected toe.

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