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156
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In hand
T
Do’s Don’ts
Do examine hand carefully Do not incise every infected digit
Do think of other diagnosis Do not make puncture incisions or over pads
Do wait for abscess to localise Do not injure the digital nerves or vessels
Do place adequate length and depth of incisions Do not place incisions crossing the crease line
Do immobilise, elevate the hand Do not close human bites or lacerated wounds
Do give antibiotics and proper dressings Do not forget to send pus for culture and sensitivity
SRB's Manual of Surgery
Individuals pre-disposed to the affection we are describing, observe
that it is more difficult to extend the fingers of the affected hand…
The first (interphalangeal joint) is flexed at nearly a right angle…the
most powerful efforts are insufficient to extend it…. Hence, it was
natural to conclude, that the commencement of the disease was in
the unusual tension of the palmar aponeurosis.
—Guillaume Dupuytren, 1833
It refers to localised thickening of palmar aponeurosis and later
formation of nodules with severe permanent changes in metacarpophalangeal and proximal interphalangeal joints. Terminal
interphalangeal joint is not involved as palmar aponeurosis
does not extend to terminal phalanx. It is common in males
(10:1).
It starts in ring and little fingers, with flexion of ring and little
fingers. Later involving all fingers.
There is thickening and nodule formation in the palm with
adherent skin.
It is often familial and bilateral 45%.
Pads (of fat) develop in knuckles and are called as Garrod’s
pads (in proximal IP joints).
A
CONDITIONS OFTEN ASSOCIATED WITH
B
x Plantar fasciitis 5%—Ledderhose’s disease
x Mediastinal and retroperitoneal fibrosis
x Peyronie’s disease of penis 3%
x Nodules in the face and ear
x Pellegrini-Stieda’s disease
Note:
Dupuytren’s contracture typically affects ring finger; years later little
finger is affected; but in 30% of cases little finger is primarily affected
– Peter F Early.
Aetiology:
¾
Repeated minor trauma, use of vibrating tools.
¾
Cirrhosis, alcoholism, smoking,
¾
Epileptics on treatment with phenytoin sodium.
¾
Diabetics, pulmonary tuberculosis, acquired immunodeficiency syndrome (AIDS).
¾
Other metabolic conditions.
¾
Familial—autosomal dominant.
B
Figs. 1.280A and B: Dupuytren’s contracture in the hands. Note the
involvement of the ring finger. Note the fibrous band on the other hand
as early finding.
B
x Dupuytren’s contracture
x Retroperitoneal fibrosis
x Peyronie’s disease of penis
Complications:
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¾
Restriction of hand function and so disability.
¾
Arthritis of metacarpophalangeal (MCP) and proximal
interphalangeal (IP) joints.
Treatment:
¾
Fasciotomy of palmar aponeurosis and later physiotherapy, Z plasty.
¾
In severe cases fasciectomy partial or complete.
¾
Treatment of the cause.
¾
Recurrence can occur in 5–50% cases.
Fig. 1.281: Z plasty done for Dupuytren‘s contracture.
It is a vascular injury leading to muscular infarction and subsequent contracture.
Causes:
¾
Supracondylar fracture of the humerus.
¾
IV chemotherapy; Burns.
¾
Closed forearm crush injuries.
¾
Tight plaster after reduction of fracture.
Pathogenesis:
Injury of brachial artery (tear, contusion,
spasm, compression)
Results in infarction Injury to median nerve
of forearm flexor
muscle both by ischaemia and
↓ infarction
Aseptic muscle necrosis
↓
Fibrosis of flexor muscle of forearm
↓
Contracture
Features:
Acute phase:
¾
Pain (persistent pain in forearm, hand, fingers—ominous
symptom).
¾
Pallor; Puffiness (due to oedema).
(mainly) and ulnar nerve
Pulseless (absence of radial pulse; but its presence does not
rule out the onset of impending contracture).
Paresis.
Late phase: Deformity
Deformity (due to injury to median nerve):
x Wrist joint extended.
x Extended metacarpophalangeal joints.
x Flexed interphalangeal joints.
Volkmann’s sign:
In early stage, the fingers can be extended at the interphalangeal
joints, only when the wrist is flexed fully. The fingers tend to flex if
any attempt to extend the wrist is made.
Treatment:
In acute phase:
¾
Removal of plastic cast applied after fracture reduction.
¾
Correction of fracture.
¾
Exposure of brachial artery and application of 2.5%
papaverine sulphate to relieve the spasm if any.
¾
Suture of arterial tear if present, often with placement of
arterial graft.
¾
Lateral incision over the deep fascia of forearm is placed
to decompress the oedema.
In late phase (once deformity occurs):
¾
Physiotherapy, Dynamic splints.
¾
Max-Page operation: Release of flexor muscles (forearm
muscles) from their origins from the bone and allowing
it slide down until full extension.
¾
Excision of fibrous tissue and damaged muscles along
with tendon transfer; Arthrodesis.
SYNDACTYLY
It is webbing or fusion of fingers.
Causes: Congenital and hereditary—common; Traumatic
like burns.
TYPES
B
x Cutaneous—simple.
x Fibrous.
x Bony—complex.
x It can be unilateral or bilateral.
x Often all four limbs may be involved with webbing of toes.
x It may be associated with polydactyly or visceral anomalies.
x If bony type is suspected, X-ray of the part should be taken.
Treatment:
¾
If cut ised which leads to gangrene of the digit.
¾
If fibrous, release can be done.
¾
If bony type, release is difficult because blood supply may
be compromised which leads to gangrene of the digit.
Note:
• Mallet finger (Base ball finger): The terminal phalanx can not be
extended because of tear at insertion of extensor tendon or avulsion
fracture of the base of the terminal phalanx.
157
CHAPTER 1K General Surgery: Hand and Foot
“Impossible” is a word found only in the dictionary of fools.—Napoleon
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• Heberden’s nodes: These are seen in osteoarthritis, occurring behind
the distal interphalangeal joints of index, middle, little and ring fingers.
• Spina ventosa: Refers to phalangeal tuberculosis (Tuberculous
dactylitis). It is called as spina ventosa because of its appearance as
“air- filled balloon”.
SRB's Manual of Surgery
Fig. 1.282: Syndactyly.
Fig. 1.283: Syndactyly and polydactyly of both hands and both feet.
Nerve supply is by saphenous, sural, posterior tibial, superficial
and deep peroneal nerves.
CALLOSITY
It is a hard, thickened skin occurs as a protective measure
seen in wider area usually over heel and heads of metatarsals.
Fig. 1.286: Callosity in the foot.
A callosity protrudes outwards from the skin.
It is greyish-brown, raised, protruded outwards, thickened,
hypertrophic skin occurs due to occupation and skeletal
structure. It is painless. It is wider lesion. Paring the top layer
exposes the shiny translucent dead skin beneath.
It is grayish brown hypertrophic raised thick protective
phenomenon which occurs commonly in areas of wear and
tear like hands and feet. Top roughened layer when peeled off,
shiny, translucent, homogenous dead skin can be exposed
beneath.
It is painless; it can get rubbed easily to create a sore.
As it is a protective phenomenon it is best left alone.
Fig. 1.284: Arthritis of joints of hands.
Fig. 1.285: Spina ventosa.
FOOT
Foot contains 7 tarsal bones, 5 metatarsals, 14 phalanges
(total 26 bones). Two sesamoid bones of 1st metatarsal bone
are common. There are 4 layers of muscles in foot. Ligaments,
muscles, joints, maintain the stability of foot complex. Blood
supply is by anterior tibial, posterior tibial and peroneal arteries.
Fig. 1.287: Diagram showing differences between corn and callosity.
CORN
Types: (1) Hard corn, (2) Soft corn.
Fig. 1.288: Corn in the plantar aspect of the foot.
Hard Corn
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It is localised area of thickening over a bony projec tions like
heads of metatarsals.
Histologically it differs from callosity by having severe kera-
toses with a central core of degenerated cells and cholesterol.
It presses over the adjacent nerves causing pain. It can get
infected causing severe pain and tender ness with inability to
walk.
It is smaller lesion which is pushed deep into the skin forming
a localised palpable painful/tender nodule with a central
yellow-white core of dead cornified skin.
Corn is common if there is deformity or by wearing tight
fitting shoes/foot wears.
Corn is narrow, deep and painful/tender.
It is common in females.
Corn is usually white/gray/yellow coloured, deep seated lesion.
Infection, abscess formation and ulceration can occur espe-
cially if patient is diabetic.
Corn may be associated with bursae causing bursitis.
Corn often recurs after excision.
Treatment:
¾
Excision.
¾
Local application of salicylic acid preparations or mixture
of salicylic acid/lactic acid/collodion may be helpful. Skin
softening agents are also tried.
¾
Eliminating the pressure is very important to prevent
recurrence.
¾
Avoid excision of corn unnecessarily in diabetic (especially with neuropathy) and in ischaemic foot.
Soft Corn
It usually occurs between 4th and 5th toes due to friction of
bases of adjacent proximal phalanges.
Both medial and lateral sides of the toe can be involved.
Recurrent attacks of acute and subacute paronychia
occurs.
Pain, tenderness, swelling of margins of the toe, often along
with granulation tissue and foul smelling discharge.
Staging: (1) Embedded toenail edge with swelling and
erythema; (2) Infection, painful discharge from nail edge;
(3) Soft tissue hypertrophy, chronic infection, granulation
tissue formation.
Treatment:
¾
Regular dressing and packing.
¾
Antibiotics. Discharge is sent for culture and sensitivity.
¾
Nails should be cut concavely or straight without leaving
lateral spikes towards soft tissues.
¾
Partial or complete matrixectomy: In recurrent
disease or in stage 3 disease partial or complete
matrixectomy is done. In partial matrixectomy, soft
tissue resection is done; then ingrown toe nail with
that part of the nail root (germinal matrix) is excised
properly. In complete matrixectomy, entire nail with
its root is removed. Incisions may be 45° angled with
root flap (Zadik’s/Fowler’s) or with L shaped incision (Frost) or ‘D’ shaped excision of the nail root
(Winograd) or ‘H’ shaped incision with removal of
the entire nail, nail root, nail bed with diseased soft
tissue resection (Kaplan). Zadik–Fowler’s radical nail
excision (1950) as partial or complete matrixectomy is
commonly used with flap elevation at angles. Phenol
matrixectomy, laser and radiosurgical matrixectomy
are also currently in use.
159
CHAPTER 1K General Surgery: Hand and Foot
PLANTAR FASCIITIS ()
It occurs due to friction or tear of the ossified posterior inser-
tion of the plantar fascia which is common in people who
stand or walk for long-time.
Treatment: Analgesics, rest, steroid injections to the site.
INGROWING TOE NAIL (Onychocryptosis)
It is also called as embedded toe nail.
It is due to curling of the side of nail inwards, causing it to
form a lateral spike resulting in repeated irritation and infection of overhanging tissues in the nail fold.
Causes: Tight shoes; Improper cutting of nails (very short
and convex).
It is common in great toe and is often bilateral.
Fig. 1.289: Zadik‘s or Fowler‘s operation.
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A
SRB's Manual of Surgery
B C
Figs. 1.290A to C: (A and B) Ingrowing toe nail. Note the granuloma
caused by repeated infection and inflammation; (C) Incision for nail
excision. Note the germinal matrix. Removal of nail, entire or partial
with adjacent germinal matrix is called as radical nail excision.
Fig. 1.291: Hallux valgus deformity.
Fig. 1.292: Hallux varus deformity. It is opposite of
hallux valgus deformity.
Note:
• Onychogryphosis: It is curving of nail upwards (Ram’s Horn Nail); It
occurs due to repeated trauma or fungal infection.
• Onychomycosis: It is fungal infection of the nail.
It is the fungal infection of the skin between the toes—Tinea pedis.
Fungi enter through cracks; survive due to moisture in
between toes.
Skin is swollen, red, with sticky fluid, macerated with blisters.
Itching, deep cracks, pain and discharge are common.
Part should be kept dry. Cotton, clean socks should be worn.
Oral antifungals, antihistaminics and topical antifungals are
used.
Condition is contagious.
Here great toe is deviated laterally at first metatarsophalangeal
joint. There is outward deviation of great toe with medial
deviation of first metatarsal head.
It may be due to persistent lateral force or occasionally
hereditary.
Condition is often bilateral.
It is common in females.
Thick walled bursa (bunion) over medial aspect of the head
of the first metatarsal bone is common.
Undue prominence of head of first metatarsal bone is typical
often forming an exostosis at this point. Osteoarthritis of 1st
metatarsophalangeal joint can occur.
Lateral deviation of proximal phalanx over 2nd toe causing
crowding of the toes.
Initially it is painless; but eventually pain and tenderness
develops with infection of bunion and splaying of forefoot.
X-ray shows deviation with often osteoarthritis of the meta-
tarsophalangeal joint.
Treatment
¾
Proximal 1/3rd of the proximal
phalanx of great toe and medial part of head of 1st metatarsal bone is excised through medial curved incision.
Soft tissue interposition is done.
¾
Medial part of base of the proximal
phalanx of great toe and head of 1st metatarsal bone is
excised—opposite of Keller’s.
¾
Varus osteotomy at the base of
1st metatarsal bone with reinsertion of adductor hallucis
tendon is done.
¾
McBride procedure: Transfer of adductor hallucis tendon
and lateral head of flexor hallucis brevis from proximal
phalanx of great toe to the lateral part of head of 1st
metatarsal bone.
¾
Arthrodesis of metatarsophalangeal joint is done to
relieve pain.
¾
Excision of bunion, deformity correction, osteotomy,
muscle transfers are also done as a combined approach.
L. Arterial Diseases
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C hapter Outline
·
Surgical Anatomy of
Thoracic Outlet
·
Arteries of Upper Limb
·
Arteries of Lower Limb
·
Arterial Diseases
·
Intermittent Claudication
·
Rest Pain
·
Limb Ischaemia
·
Different Levels of
Arterial Obstruction
·
Other Features of Poor
Circulation
·
Investigations for
Arterial Diseases
·
Diseases of the Arteries
·
Atherosclerosis
·
Thromboangiitis
Obliterans
·
Takayasu’s Pulseless
Arteritis
·
Raynaud’s Phenomenon
·
Temporal Arteritis
·
Treatment of Arterial
Diseases
·
Subclavian Steal
Syndrome
·
Acute Arterial Occlusion
·
Traumatic Acute Arterial
Occlusion
·
Embolism
·
Reperfusion Injury
SURGICAL ANATOMY OF THORACIC OUTLET
Thoracic outlet is bounded by manubrium sternum in front, spine
posteriorly, and the first rib laterally. At the superior aperture
of thorax subclavian vessels, brachial plexus traverse the cervicoaxillary canal to reach the upper limb.
Cervicoaxillary canal is divided into proximal Costoclavicular
space and distal axilla (divided by first rib).
·
Saddle Embolus
·
Embolectomy
·
Fat Embolism
·
Air/Gas Embolism
·
Therapeutic
Embolisation
·
Caisson’s Disease or
Decompression Disease
·
Aneurysm
·
Mycotic Aneurysm
·
Abdominal Aneurysm
·
Abdominal Aortic
Aneurysm
·
Peripheral Aneurysm
·
Carotid Artery Aneurysm
·
Dissecting Aneurysm
·
Erythromelalgia
·
Livedo Reticularis
·
Polyarteritis Nodosa
·
Scleroderma/Systemic
Sclerosis
·
Acrocyanosis
·
Gangrene
·
Diabetic Foot and
Diabetic Gangrene
·
Frostbite
·
Ainhum
·
Endovascular Surgeries
·
Upper Limb Ischaemia
·
Arterial Substitutes
Costoclavicular space is bounded superiorly by clavicle, inferiorly
by first rib, anteromedially by the costoclavicular ligament, and
posterolaterally by scalenus medius muscle along with long
thoracic nerve.
Scalenus anticus muscle divides the costoclavicular space
into two compartments, the anterior one containing subclavian
vein and the posterior one containing subclavian artery and
brachial plexus.
This posterior compartment is called as Scalene triangle
bounded by scalenus anticus anteriorly, scalenus medius posteriorly, and the first rib inferiorly.
Cervical rib narrows this triangle and causes compressive features of the C8, T1 nerve roots and subclavian artery.
Anything that narrows costo clavicular space causes Thoracic
outlet syndrome.
ARTERIES OF UPPER LIMB
Right subclavian artery begins from brachiocephalic trunk
(innominate artery) whereas left subclavian artery arises directly
from the arch of aorta. From underneath the sternoclavicular
joint artery arches over the pleura and apex of lung about 2.5
cm above the clavicle and then reaches the lateral border of first
rib to continue as axillary artery.
Subclavian artery is divided into three parts by scalenus
anterior muscle.
Axillary artery is divided into three parts by pectoralis minor
muscle.
At the lower border of teres major muscle it enters the arm
and continues as brachial artery.
About 2.5 cm below the crease of the elbow joint, it bifurcates
into radial and ulnar arteries which run in the forearm.
Ulnar artery forms the superficial palmar arch which is
completed by superficial palmar branch of radial artery.
Radial artery after passing through the anatomical snuff
box enters the dorsum of hand and first intermetacarpal space
to form deep palmar arch. It is completed by deep palmar
branch of ulnar artery and is 1 cm proximal to superficial
palmar arch.
ARTERIES OF LOWER LIMB
Abdominal aorta bifurcates at the level of fourth lumbar vertebra
(corresponds to the level of the umbilicus in anterior abdominal
wall) into two common iliac arteries.
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Common iliac artery is about 5 cm in length passes downward
and laterally; and at the level of lumbosacral intervertebral disc,
anterior to sacroiliac joint, it divides into external and internal
iliac arteries. Internal iliac artery supplies pelvic organs.
External iliac artery continues as common femoral artery at
the level of inguinal ligament.
About 5 cm below the inguinal ligament common femoral
divides into superficial femoral and deep femoral (Profunda
femoris) arteries.
Deep femoral artery provides collateral circulation around the
knee joint and also communicates above with gluteal vessels to
maintain collateral circulation around the gluteal region.
SRB’s Manual of Surgery
Superficial femoral artery at the hiatus in the adductor
magnus, continues as popliteal artery up to the inferior angle of
the popliteal fossa where it divides into anterior and posterior
tibial arteries.
Anterior tibial artery supplies anterior compart ment of leg
and ankle, continues as dorsalis pedis artery which forms dorsal
arterial arch of the foot.
Posterior tibial artery supplies posterior compart ment of
leg and ends as medial and lateral plantar arteries which forms
plantar arterial arch of the foot.
Posterior tibial artery gives peroneal artery which runs close
to fibula supplying calf muscles.
¾
In the abdomen causing pain, bloody stool.
¾
In the kidney causing haematuria.
Dilatations are aneurysms.
Arteritis.
Small vessel abnormalities.
INTERMITTENT CLAUDICATION
Claudio means “I limp” a Latin word. It is a crampy pain in the
muscle seen in the limbs. Due to arterial occlusion, metabolites
like lactic acid and substance P accumulate in the muscle and
cause pain.
The site of pain depends on site of arterial occlusion:
The most common site is calf muscles.
Pain in foot is due to block in lower tibial and plantar vessels
(70%).
Pain in the calf is due to block in femoropopliteal segment.
Pain in the thigh is due to block in the superficial femoral
artery.
Pain in the buttock is due to block in the common iliac or
aortoiliac segment (30%), often associated with impotence
and is called as Leriche’s syndrome.
Pain commonly develops when the muscles are exer cising.
Cause for pain is accumulation of sub stance P and metabolites.
During exercise increased perfusion and increased opening of
collaterals wash the metabolites.
A B
Figs. 1.293A and B: CT angiogram of aortoiliac segment showing
aortoiliac block due to atherosclerosis. Collaterals are also welldeveloped.
ARTERIAL DISEASES
Stenosis due to trauma, atherosclerosis, emboli. It may be:
¾
In the brain causing transient ischaemic attacks.
¾
In the limbs causing claudication and rest pain.
BOYD’S CLASSIFICATION OF CLAUDICATION
B
x Grade I: Patient complains of pain after walking, and distance
in which pain develops is called as ‘claudication distance’. If
patient continues to walk, due to increased blood flow in muscle
and opening of collaterals metabolites causing pain are washed
away and pain subsides
x Grade II: Pain still persists on continuing walk; but can walk
with effort
x Grade III: Patient has to take rest to relieve the pain
CLAUDICATION
B
x Arterial—typically develops after walking for certain distance
and resolves rapidly within 5 minutes once walking is stopped
x Neurogenic—pain develops in standing or walking and disappears
immediately after stopping walk; normal feeling pulses without
ischaemic changes are present. It is usually due to narrow lumbar
canal (spinal canal stenosis)
x Venous—it is rare but definitely occurs. It is observed in chronic
pelvic venous obstruction as a mechanical high venous pressure.
It is usually due to iliac vein thrombosis. Peripheral pulses are
normal
Note:
• Beta blockers may aggravate claudication.
• Claudication is not that common in upper limb but can occur during
writing or any upper limb exercise.
• Criteria to diagnose intermittent claudication: (1) Cramp like pain
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in a muscle—calf muscle. (2) Pain develops only when muscle is
exercised. (3) Pain disappears when exercise stops within 5 minutes.
• Intermittent claudication is due to anaerobic muscle metabolism.
• Superficial femoral artery is most commonly affected (70%) causing
calf claudication.
• ABPI decrease by 0.1 below the 0.9 carries 10% increase in relative
risk (RR) of major cardiovascular disease in patient with claudication.
REST PAIN
It is continuous aching in calf or feet and toes or in the region
even at rest depending on site of obstruc tion.
It is ‘cry of dying nerves’ due to ischaemia of the somatic
nerves. It signifies severe decompensated ischaemia. Pain
gets aggravated by elevation and is relieved in dependent
position of the limb.
Pain is more in the distal part like toes and feet. It gets aggra-
vated with movements and pressure.
Hyperaesthesia is common association with rest pain.
Rest pain is increased in lying down and elevation of foot; it
may be reduced on hanging the foot down.
Rest pain is worst at night and so patient is sleepless at
night. During sleeping at night heart rate and blood pressure
diminishes which further aggravates the hypoperfusion and
rest pain.
Rest pain is apparently reduced by holding the foot with
hand, probably due to suppression of transmission of pain
sensation.
Anaerobic muscle metabolism occurs even at rest mainly
affecting the foot and leg.
FEATURES OF ARTERIAL STENOSIS/BLOCK IN LIMBS
B
x Intermittent claudication, rest pain
x Cold periphery, numbness, paraesthesia
x Colour changes, ulceration, gangrene
x Altered sensation and decreased function/movements
x Diminished/absent arterial pulsation
x Thrill/bruit over the stenosed artery
x Altered venous filling—normally it is in few seconds; it is delayed
in arterial stenosis; it is rapid in AV fistula
LIMB ISCHAEMIA
Causes
Atherosclerosis.
Embolism (acute).
Arteriopathies—Buerger’s disease, Raynaud’s disease,
Takayasu’s disease.
Diabetes.
Scleroderma.
Physical agents—trauma, tourniquet, radiation injury.
Classication of Limb Ischaemia
FONTAINE CLASSIFICATION OF LIMB ISCHAEMIA
B
x Stage 1: No clinical symptoms
x Stage 2: Intermittent claudication
– 2a: Well-compensated—can walk >200 metres
– 2b: Poorly compensated—walk only <200 metres
x Stage 3: Rest pain
x Stage 4: Gangrene, ischaemic ulcer
163
CHAPTER 1L General Surgery: Arterial Diseases
Fig. 1.294: Rest pain in a patient suffering from TAO. Holding the
foot reduces the pain slightly.
Rutherford classification
T
Grade Clinical feature
0
1
2
3
4
5
6
Asymptomatic
Mild claudication
Moderate claudication
Severe claudication
Ischaemic rest pain
Minor tissue loss
Major tissue loss
Limb ischaemia is also classified as:
Functional ischaemia; Critical ischaemia.
Functional Limb Ischaemia
Here flow of blood is normal when limbs are at rest; but will
not be increased during exercise. It presents as claudication.
It is defined as, “Muscle discomfort in the limb reproducibly
produced by exercise and relieved by rest within 10 minutes.”
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Critical Limb Ischaemia
It is persistently recurring ischaemic rest pain for 2 weeks,
which requires regular analgesics for >2 weeks or ulceration
or gangrene of the foot or toes with an ankle systolic pressure <50 mmHg or toe systolic pressure <30 mmHg. Ankle
brachial pressure index (ABPI) will be less than 0.3.
One should check blood pressure in all 4 limbs. ABPI is
checked in supine position; systolic blood pressure in
upper and lower extremities (two upper and two lower) is
checked and higher value of each extremities is taken; ABPI
is calculated.
SRB’s Manual of Surgery
Results: ABPI >0.9 is normal; 0.70–0.89 is mild ischaemia;
0.50 – 0.69 is moderate ischaemia; <0.5 is severe (rest pain);
<0.3 critical ischaemia (tissue necrosis).
Drawbacks: Calcification of the vessel wall may make vessel
incompressible causing high ABPI >1.3 which is often
observed in diabetics. In a patient with intermittent claudication ABPI may be apparently normal and if it is so ABPI
should be rechecked after exercise when the pain develops
which will show the drop in ABPI >20% of earlier one; it may
suggest significant ischaemia.
A B
Figs. 1.295A and B: (A) Dry gangrene; (B) Wet gangrene.
Fig. 1.297: Skip lesions in ischaemic limb.
Pregangrene: It is the changes in tissue which indicates
that blood supply is inadequate to keep the tissues alive and
presents with rest pain, colour changes, oedema, hyperaes-
thesia with or without ischaemic ulceration.
Gangrene: It is macroscopic death of tissue in situ with
putrefaction. Organs in which gangrene can develop are—
appendix, bowel, gallbladder, testis and pancreas.
¾
Dry gangrene: It is dry, desiccated, mummified tissue
caused by gradual slowing of bloodstream. There is clear
line of demarcation and is localized.
¾
Wet gangrene: It is due to both arterial and venous block
along with superadded infection and putrefaction. It
spreads proximally and there is no clear line of demarcation. It spreads faster.
Necrosis: It is microscopic cell death.
Sequestrum is dead bone in situ.
Slough is dead soft tissue in situ.
Line of demarcation: It is a line between viable and dying
tissue indicated by a band of hyperaemia. It also indicates that
disease is getting localised. Final separation between healthy
and gangrenous tissue occurs by development of a layer of
granulation tissue in between. It is hyperaesthetic due to
ischaemia and irritation of exposed nerve endings. Types of
separations in line of demarcation: (1) Separation by aseptic
ulceration is seen in dry gangrene. (2) Separation by septic
ulceration is seen in infected condition and wet gangrene.
Fig. 1.296: Ischaemic ulcer in the heel.
Fig. 1.298: Gangrene of great and little toes in a patient with
vascular compromise.
Fig. 1.299: Ischaemic ulcer foot in a diabetic patient.
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A B
Figs 1.300A and B: Gangrene of all toes at their distal phalanges.
All ischaemic features are obvious.
Fig. 1.301: Ischaemic changes in the right leg. Third and fourth toes
are gangrenous with line of demarcation. Great and little toes are partly
gangrenous. There are ischaemic features in the right foot and leg like
hair loss/skin changes/wasting.
FEATURES OF ISCHAEMIA
B
x Marked pallor, purple blue cyanosed appearance
x Thinning of skin, diminished hair, loss of subcutaneous fat
x Brittle nails, with transverse ridges
x Ulceration in digits, wasting of muscles
x Tenderness and temperature (cold)
Fig. 1.302: Clear line of demarcation in gangrenous 4th toe.
DIFFERENT LEVELS OF ARTERIAL OBSTRUCTION
Aortoiliac block causes claudication in both buttocks, thighs,
and calves; absence of femoral and distal pulses, bruit over
aortoiliac region. Impotence occurs due to defective perfusion
through internal iliac arteries and so into the penis causing
erectile dysfunction (Leriche’s syndrome).
Iliac artery obstruction causes claudication in thigh and calf;
bruit over iliacs with absence of femoral and distal pulses.
Femoropopliteal obstruction causes claudication in calf with
absence of distal pulses but with palpable femoral.
Distal obstruction shows absence of ankle pulses with
palpable femoral and popliteal pulses.
¾
Paraesthesia over the skin of the foot is due to shunting
of blood from the skin to muscles in deeper plane.
¾
Sensation in gangrenous area is absent. But, at the line
of demarcation, skin is hyperaesthetic.
OTHER FEATURES OF POOR CIRCULATION
The affected part is cold with numbness, paraesthesia and
colour changes. Observing for colour change is important as,
if it is not present one may have to think that numbness could
be of neurological origin. On elevation the part blanches, on
dependency part becomes purple. Temperature sensation on
the ischaemic limb is lost apart from its coldness.
Ulceration, gangrene, decreased sensation and movements
are the features to be checked.
Delayed capillary filling: Blanched nails or pulp of fingers,
on pressure, will show delay in refilling (to turn pink) after
release of pressure.
Delayed venous refilling: Two fingers are placed over the
vein. Finger nearest to heart is moved away so as to empty the
vein. Distal finger is released to observe the venous refilling.
Delay in filling is called Harvey’s sign, signifies ischaemia.
Venous filling is increased in AV fistulas.
Crossed leg test (Fuchsig’s test): Patient is asked to sit
with the legs crossed one over the other so that the popliteal
fossa of one leg will lie against the knee of other leg. Oscilla-
tory movements of foot can be observed synchronous with
165
CHAPTER 1L General Surgery: Arterial Diseases
Severely diseased distal aorta in atherosclerosis on arteriography is called as “shaggy aorta”.
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