11 year old girl presented will complain of blackish discoloration of right hand fingers for 6-7 months. History of intravenous injection 7 month back and patient developed a gangrenous patch which is gradually increasing. C/o pain in right hand. On examination gangrenous of all 5 digits present. Radial artery is feeble. Wrist extenders are week. Patient also complaining of right sided chest pain. How to manage this patient and what could be cause of chest pain ?



Probable iatrogenic vascular injury leading to thrombotic occlusion, ischemia and later gangrene right hand digits. Other Differentials are vasculitis, autoimmune, thromboangitis obliterance and iv injection could only be an incidental preceding factor Examination: Palpate all limbs pulsations for comparison and documentation USG doppler right upper limb, if need be CT angiography ECG ( for chest pain) cardiogenic thromboembolism can present this way, 2D ECHO if indicated CXR Management: Analgesics Anticoagulation- LMWH in case of thrombosis Cilastazole, Atorvastatin, Pregabalin ( after PAD documentation) Respective treatment for vasculitis, autoimmune disorder

Doppler study should be done for loss of blood supply.. Many etiolgy nerrated. Detail clinical history and neurologicl exam needed. Surgeon opinion for Amputation to prevent infectioon and trauma , extension.

This patient has gangrene of distal phalanx of all five fingers of right hand There is no doubt that she needs amputation of gangrenous portion of finger, however it is not an emergency as it is a dry gangrene of finger tips. One can wait for spontaneous amputation to occur Another most important issue is to determine cause of gangrene of finger It is a rare condition and causes need to be investigated meticulously Differential diagnosis Connective tissue disease Hypersensitivity angiitis Arteriosclerosis Myeloid metaplasia, Calciphylaxis Carcinoma with paraneoplastic syndrome ANCA associated vasculitis Systemic lupus erythematosus Antiphospholipid syndrome Lupus anticoagulant Cardiac pathology with embolization of digital vessels

Very gloomy situation, the nature of the injection is not known, but normally no intravenous injection would lead to such an extensive gangrene of the hand, hence before coming to the conclusion it better to do thorough examination and investigation to rule out thromboembolic problem, vasoocclusive disorders, in the end the brunt is already done, patient should be treated with conservative amputations , preserving as much normal parts as possible with reconstruction.

Unilateral Digital gangrene Need evaluation Reason for late presentation? Something was hidden by parents.. CT angiography arterial Evaluate ankle brachial index Blood cultures Tissue biopsy. As of now amputation of digits is the only option

Color Doppler. Gangrene. Diabetes

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Demarcated gangrene in all fingers One cause for chest pain could be neuralgia that is common in injured limbs Doppler/CT angiogram to assess arterial occlusion

Raynods or Burger's disease Rt chest pain xray chest ecg R/0 embolism pulmonary Artery occlusion Color Doppler Ct angiogram

Opinion of vascular surgeon Removal of clot or anastomosis

Gross medical negligence whomsoever may be concerned H/o intravenous injection preceding of this event suggest counter extravasetion was not attended as it seems radial arteritis as a result of extravasetion of chemicals injected intravenously caused inflammation and occlusion of major arteries like radial and not attended for 6to7 months resulted in spread of arteritis rt arm and hence pain in rt chest Gangrenous fingers suggest the extreme carelessness Immidiately colour doppler study of affected limb should be done to study thrombosis of vessel and its extension Take help of vascular surgeon earliest to save the upper limb otherwise it may need Amputation

Thank you sir.

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