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Dry Gangrene of Toes

Dry Gangrene with Ischemic Necrosis OF THE Skin

Dry Gangrene of Heel

Dry Gangrene of All Toes

Wet Gangrene and Sepsis

Dry Gangrene of the Toe


Digital Subtraction Angiography

Wet Gangrene of the Toes

Wet Gangrene of the Foot

Wet Gangrene Leading to Mid-Tarsal Disarticulation

Extensive Wet Gangrene of the Foot

Wet Gangrene of the Hallux


A 65-year-old male patient with type 2 diabetes diagnosed at the age of 61 years and treated with sulfonylurea, was admitted to the Vascular Surgery Department. He was a heavy smoker and had a sedentary lifestyle. He had hypertension, background diabetic retinopathy and dyslipidemia (triglycerides: 4 mmol/l; HDL-cholesterol: 0.67 mmol/l). His diabetes control was poor (HBA1c: 8.5%). The patient complained that in the previous 3 weeks he had experienced pain which required analgesia when he was at rest. He had typical symptoms of intermittent claudication for 2 years with progressive worsening.

On examination, extensive dry gangrene was found involving all the toes and with a necrotic area over the dorsum of his left foot (Figure 7.1). The foot arteries and left popliteal artery could not be felt, while the femoral arteries were just palpable bilaterally. Pulses in the right foot arteries were absent; the skin was cold and the right popliteal artery was just palpable. The ankle brachial index was 0.4. The patient had reduced sensation of pain, light touch and temperature. The vibration perception threshold was 35 V on the left and 30 V on the right foot. Critical limb ischemia with dry gangrene was diagnosed; an angiogram showed extensive stenosis of the common iliac, superficial femoral and popliteal arteries of both feet. Aorto-femoral and femoro-popliteal bypass grafts were undertaken 2 days after admission, followed by mid-tarsal disarticulation (at Lisfranc's joint). The postoperative period was without any complications and the wound healed completely.

Gangrene is characterized by the presence of cyanotic, anesthetic tissue associated with or progressing to necrosis. It occurs when the arterial blood supply falls below minimal metabolic requirements. Gangrene can be described as dry or wet. Wet gangrene is dry gangrene complicated by infection (see below, and Figures 7.24 and 7.25).

Dry gangrene is characterized by its hard, dry texture, usually occurring in the distal aspects of the toes, often with a clear demarcation between viable and necrotic tissue. Once demarcation occurs, as is the case in this patient, the involved toes may be liable to auto-amputation. However, this is a long (several months) and unpleasant process. In addition, many patients do not have an adequate circulation to heal a distal amputation. For these reasons it is common practice to evaluate the arteries angiograph-ically and to carry out a bypass or a percutaneous transluminal angioplasty with concomitant limited distal amputation, in order to improve the chances of wound healing.


Critical leg ischemia is defined—according to the consensus statement on critical limb ischemia—as either of the following two criteria: persistently recurring ischemic rest pain, requiring regular adequate analgesia for more than 2 weeks, with an ankle systolic pressure <50 mmHg and/or a toe pressure <30 mmHg; or ulceration or gangrene of the foot or toes, with an ankle systolic pressure <50 mmHg and/or a toe pressure <30 mmHg. In such patients it is important to differentiate neuropathic pain from ischemic rest pain (neuropathic pain typically occurs or worsens at rest in the night). Measurement of the ankle brachial index or toe pressure can easily differentiate the two conditions.

Keywords: Dry gangrene; critical limb ischemia

Necrotic Toes
Figure 7.1 Dry gangrene involving all the toes of the left foot with a necrotic area over the mid-dorsum. Note the hard, dry texture and the clear demarcation between viable and necrotic tissue. (Courtesy of E. Bastounis)

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  • wilcome
    How to treat the pain from a necrotic limb?
    8 years ago
  • michelino
    Which toe in the foot is the least important?
    8 years ago
  • heikki
    How to differentiate gangrene?
    7 years ago

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