Wet Gangrene Of The Hallux

A 72-year-old male patient with type 2 diabetes diagnosed at the age of 60 years and being treated with insulin, attended the outpatient diabetic foot clinic because of pain in his right hallux. His diabetes control was poor (HBA1c: 8.7%). He had hypertension and background retinopathy in both eyes. He was an ex-smoker. The patient had

Wet Gangrene
Figure 7.28 Wet gangrene of the right hallux and claw toe deformity. Ischemic hair, redness over toes, dystrophic nail changes) can also be seen

changes (loss of

Superficial Femoral Artery Stenosis

Figure 7.29 Triplex scan of the foot shown in Figure 7.28. Increased peak systolic velocity (PSV) of blood flow (269 cm/s) through the stenotic segment of the left common femoral artery, biphasic flow pattern and widening of the spectral window under systolic peak can be seen (normal PSV in the common femoral artery is approximately 100 cm/s). These findings correspond to a stenosis of the left common femoral artery of 50-60%

Figure 7.29 Triplex scan of the foot shown in Figure 7.28. Increased peak systolic velocity (PSV) of blood flow (269 cm/s) through the stenotic segment of the left common femoral artery, biphasic flow pattern and widening of the spectral window under systolic peak can be seen (normal PSV in the common femoral artery is approximately 100 cm/s). These findings correspond to a stenosis of the left common femoral artery of 50-60%

Posterior Tibial Vein Ultrasound Images

Figure 7.30 Triplex scan of the foot shown in Figures 7.28 and 7.29. The spectral window in the right posterior tibial artery is biphasic, the spectrum is wide and the peak systolic velocity (PSV) is reduced (PSV at this level is expected to be about 50 cm/s). These findings denote a proximal stenosis of approximately 60%

Figure 7.30 Triplex scan of the foot shown in Figures 7.28 and 7.29. The spectral window in the right posterior tibial artery is biphasic, the spectrum is wide and the peak systolic velocity (PSV) is reduced (PSV at this level is expected to be about 50 cm/s). These findings denote a proximal stenosis of approximately 60%

Figure 7.31 Triplex scan of the foot shown in Figures 7.28-7.30. The spectral waveform of the right anterior tibial artery is biphasic, the spectral window is wide, the peak systolic velocity is decreased, the velocity during diastole is increased and the downslope of the waveform is delayed. This pattern of flow is described as tardus pardus and corresponds to the presence of a proximal stenosis of 60-70%

Figure 7.31 Triplex scan of the foot shown in Figures 7.28-7.30. The spectral waveform of the right anterior tibial artery is biphasic, the spectral window is wide, the peak systolic velocity is decreased, the velocity during diastole is increased and the downslope of the waveform is delayed. This pattern of flow is described as tardus pardus and corresponds to the presence of a proximal stenosis of 60-70%

Figure 7.32 Triplex scan of the foot shown in Figures 7.28-7.31. Examination of the left anterior tibial artery shows a monophasic waveform, indicating that a stenosis of greater than 80% is present

Figure 7.32 Triplex scan of the foot shown in Figures 7.28-7.31. Examination of the left anterior tibial artery shows a monophasic waveform, indicating that a stenosis of greater than 80% is present ischemic rest pain due to peripheral vascular disease (Fontaine's stage IV). Six days earlier he had become aware of a worsening pain in his right hallux, the onset of which had been acute.

On examination, wet gangrene was noted on the right hallux; peripheral pulses were absent and the ankle brachial index was 0.4 bilaterally. He had severe peripheral neuropathy (no Achilles tendon reflexes, loss of sensation of 5.07 monofilaments and vibration; the vibration perception threshold was 45 V in both feet) and claw toe deformity. In addition, ischemic changes of his feet were also noted (loss of hair, redness over toes, dystrophic nail changes, and cold feet) (Figure 7.28).

Onychocryptosis was the cause of his gangrene due to inappropriate nail care, resulting in paronychia and localized ischemic necrosis. The patient was treated with amoxicillin-clavulanic acid. A color duplex scan (triplex) of the leg arteries showed mild atheromatous stenosis in his iliac and common femoral arteries (see below), and severe stenosis in his right superficial femoral artery. An angiogram confirmed the ultrasound findings and revealed a >95% stenosis in the middle of his right superficial femoral artery, with the development of collateral circulation. The right anterior tibial artery was almost completely obstructed just after to the popliteal artery trisection; the foot arteries were patent.

The patient underwent a right aorto-popliteal and a popliteal-peripheral bypass. His recovery was good and the infected hallux improved gradually.

Education in foot care was provided. The patient was advised to wear appropriate footwear.

Increased peak systolic velocity (PSV) of blood flow (269 cm/s) through the stenotic segment of the left common femoral artery, a biphasic flow pattern and widening of the spectral window under the systolic peak were observed (Figure 7.29) (normal PSV in the common femoral artery is approximately 100 cm/s). These findings correspond to a 50-60% stenosis in the left common femoral artery. The spectral window in the right posterior tibial artery (Figure 7.30) was also biphasic, the spectrum was wide and the PSV was reduced (PSV at this level is expected to be about 50 cm/s) indicating that a proximal stenosis of approximately 60% was present. The waveform of the right anterior tibial artery (Figure 7.31) was biphasic, the spectral window was wide, the peak systolic velocity was decreased, the velocity during diastole was increased and the downslope of the waveform was delayed. This pattern of flow is described as tardus pardus and corresponds to the presence of a proximal stenosis of 60-70%. Examination of the left anterior tibial artery (Figure 7.32) showed a monophasic waveform, indicating that a stenosis of greater than 80% was present.

Keywords: Dry gangrene; dystrophic nails; onychocryptosis; ingrown nail; triplex scanning; peak systolic velocity; evaluation of arterial stenosis

Atlas of the Diabetic Foot. N. Katsilambros, E. Dounis, P. Tsapogas and N. Tentolouris Copyright © 2003 John Wiley & Sons, Ltd.

ISBN: 0-471-48673-6

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Responses

  • Ottavio Costa
    What is gangrene of hallux?
    7 years ago
  • rita
    What is spectral window on ultrasound?
    7 years ago
  • Laila
    Where Is The Posterior Tibial Vein?
    6 years ago
  • VELI
    What is a monophasic waveform?
    6 years ago
  • cedric paschall
    How to tell monophasic from biphasic in ultrasound?
    3 years ago

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