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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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