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09/11/2013 Name WQithheld (FL)
Gangrene S/P Cast Complication (Khurram Khan, DPM)
I would like to weigh in on this case since I have actually seen the patient. I tend to disagree with some of the answers provided and think they are more of a textbook solution. This foot has profound vascular compromise. This is a 16 year old with gangrene to the toes with 3 weeks of no treatment. Perhaps at the very early stages some of these treatments may have been appropriate but that is no longer the case.
So first off, this poor child should have had been admitted and had an immediate vascular consult 3 days post-op when his toes were purple in a cast. Was there vascular compromise during surgery? This would not be to CYA but he actually needs to be under the care of a vascular surgeon for limb salvage working along with a podiatrist to identify the injury site and amount and level of perfusion.
So I have referred him to a vascular surgeon. That's because it is the best medical option for the survival of the foot; it is the first thing that should have been done. I saw this patient at 3 weeks post-op for the first time. The orthopod wanted "nature to take its course" and indeed he got his wish!
So what is in the best interest of this unfortunate 16 year old? He will not bounce back from this and will certainly require digital amputations. Nitropaste is no longer an option for dead toes. Hyperbaric does not work if there is no perfusion to the toes and other portions of the foot. In my opinion, this has deteriorated way beyond HBOT. What is more important is identifying where the vascular compromise occurred.
This injury was not strictly caused by applying a cast. Dr. Khan hit the nail on the head. Look at the medial incision, it runs across the neurovascular bundle and that site was compromised either by transection or by compartment syndrome. This was an elective tendon transfer procedure. The cast was what added insult to injury.
I will keep all of you updated on this case. My hope is that he will only have toe loss and no further.
Name Withheld
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