Dry Gangrene Pictures

Leon S. Benson

History and Clinical Presentation

The hand surgery service was called to evaluate the thumb and index finger of a 75-year-old woman. The patient had been admitted to the hospital 1 week previously for heart failure. Twenty-four hours after admission she became increasingly hypotensive and was transferred to the intensive care unit. A Swan-Ganz catheter was placed, the patient was intubated, and a left wrist arterial line was inserted. On hospital admission day 7, the patient was still in the intensive care unit and intubated but she was slowly improving. However, it was then noted that her thumb and index finger, which had looked "dusky" on the previous day, were now turning black and rigid (Figs. 25—1 and 25—2) even though the radial artery catheter had been removed on the previous day.

Physical Examination

Examination of the left hand demonstrated dry gangrene of the thumb that was sharply demarcated distal to the midportion of the proximal phalanx. The left index finger also demonstrated dry gangrene, although a more gradual zone of transition was present, with grossly necrotic tissue being present circumferentially distal to the distal interphalangeal joint. No other soft tissue compromise was noted about the hand. A normal ulnar pulse was easily palpable at the wrist, whereas a radial pulse was undetectable, either by palpation or Doppler examination. A small puncture wound and 3-cm ecchymotic area were present where the radial pulse normally would have been palpable. Nursing staff noted that this was the site of arterial line placement when the patient was first admitted to the intensive care unit. The line, which was an 18-gauge angiocatheter, had been removed 2 days earlier when it seemed to be dysfunctional.

Angiocatheter
Figure 25—1. Clinical presentation of the volar surface with a black and rigid appearance with sharp demarcation demonstrating dry gangrene.
First Arch Syndrome

Figure 25—2. Clinical presentation of the dorsal surface with a black and rigid appearance with sharp demarcation demonstrating dry gangrene.

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