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GANGRENE

Introduction

Gangrene is a serious condition in which the occluded supply of blood results in the death and decay of body tissue. Gangrene is actually the end result of tissue ischemia that can have many underlying and overlapping causes.  In the extremities muscle tissue is particularly vulnerable to ischemia. However, gangrene can affect any part of the body, but most commonly starts in the fingers and toes. The most common causes of gangrene include infection, traumatic injuries, and long-term conditions that restrict blood circulation, including diabetes, vascular diseases, arterial steal syndrome secondary to the AV fistula and Raynaud’s phenomenon. Microvascular thrombosis which is often associated with disseminated intravascular coagulation (DIC) can also lead to two additional forms of gangrene where the pulses remain in intact.  One is venous limb gangrene and the other is symmetrical peripheral gangrene.6  Once the flow of blood is completely blocked, the area affected by the impeded vessels will eventually turn blue, with other extreme skin changes, pain, coldness, and a foul-smelling discharge also occurring in most cases. Urgent treatment is crucial, as the condition can lead to death if treatment is delayed, the gangrene is too extensive, or the person has other significant medical problems. Management may include a combination of medical and surgical interventions like fasciotomies and amputations.  Amputation may be necessary in severe cases to prevent the spread of gangrene to other parts of the body and save the patient's life.1,2,6

Pathophysiology

  • Any event or condition that narrows blood vessel(s) and/or contributes to the complete obstruction of blood flow can lead to gangrene, with some of the most common causes including infection, injury, and long-term conditions affecting blood circulation
    • Conditions that increase the chances of gangrene developing include diabetes, atherosclerosis, peripheral arterial disease, and Raynaud’s phenomenon
    • Traumatic injuries that damage the skin and/or tissues such as car accidents, frostbite, and burns can all result in blood loss, and open wounds can also be vulnerable infection, which collectively can increase the chances of developing gangrene
    • In critically ill patients, venous gangrene of the hand or upper limb can result from the placement of an indwelling venous catheter2
    • Gangrene of the hand can also result from unsuccessful attempts at internal jugular vein cannulation, which can lead to upper limb vein occlusion and eventually gangrene2
    • Immunosuppression, which can result from chemotherapy or radiation, history of injecting drugs, malnutrition, older age, obesity, kidney failure, alcohol abuse, and smoking, is also associated with a higher risk for gangrene
    • Other factors that can increase the risk for gangrene include asplenia, previous cold injury to extremities, renal failure, increased sympathetic tone, and the use of vasopressors1

Related Anatomy

  • Gangrene is typically classified into two primary types:
    • Dry gangrene
      • Starts more slowly than wet gangrene
      • Commonly associated with chronic diseases like diabetes and atherosclerosis
  • Wet gangrene
    • More aggressive form of gangrene
    • Associated with infections of affected tissues
    • May occur and progress in diabetic patients with neuropathy
    • Gas gangrene, or clostridial myonecrosis, is a particularly virulent form of wet gangrene that can affect the hands and upper extremities.  This infection is associated with poorly irrigated and debrided wounds.  These infections are frequently cause by traumatic wounds that are exposed to contaminated soil like that found in a barn yard.3
      • Dry forms of gas gangrene can also result from a progressive loss of blood supply to tissues, and can become wet if they develop a bacterial infection
      • Other less common types of gangrene include internal gangrene, which can be due to surgical complications, necrotizing fasciitis (NF) and Fournier’s gangrene (NF of the perineal and genital areas).  These infections are sometimes referred to as emolytic streptococcal gangrene

Incidence and Related Conditions

  • Gangrene of the hand associated with acute venous occlusive disease of the upper limb is rare, with only 16 cases reported as of 20092
  • The annual incidence of atheroembolism that leads to ischemic gangrene in atherosclerosis patients is 0.3–3.5% overall, but can rise to 30% after vascular procedures4
  • The annual incidence of gas gangrene in the U.S. is approximately 3,000 cases5
  • Urosepsis
  • Sepsis
  • Phlegmasia cerulea dolens
  • Vascular insufficiency
  • Microbial infection
  • Ischemia
  • Necrosis

Differential Diagnosis

  • Staphylococcal skin lesions
  • Erysipelas
  • Cellulitis
  • Insect bite
ICD-10 Codes

  • GANGRENE

    Diagnostic Guide Name

    GANGRENE

    ICD 10 Diagnosis, Single Code, Left Code, Right Code and Bilateral Code

    DIAGNOSISSINGLE CODE ONLYLEFTRIGHTBILATERAL (If Available)
    GANGRENEI96   

    ICD-10 Reference

    Reproduced from the International statistical classification of diseases and related health problems, 10th revision, Fifth edition, 2016. Geneva, World Health Organization, 2016 https://apps.who.int/iris/handle/10665/246208

Clinical Presentation Photos and Related Diagrams
Gangrene
  • Dry gangrene associated with chronic diabetes and secondary peripheral vascular disease.
    Dry gangrene associated with chronic diabetes and secondary peripheral vascular disease.
Symptoms
Pain and severe swelling sometimes with tense fascial compartments
Paresthesia/numbness
Shiny skin and cyanosis sometimes with foul-smelling discharge
Sores/blisters
Coldness and skin pallor
Typical History

The typical patient is a 57-year-old woman with atherosclerosis and type 2 diabetes, as well as resultant diabetic neuropathy that affected all of her extremities. The woman injured herself after picking up a broken flowerpot, which led to a moderate-sized laceration on the palmar side of her left hand. Although she bandaged the wound, she failed to clean it thoroughly, which allowed bacteria to infect the area. After several days, she noticed that her injured hand was getting aggressively worse and starting to turn blue and smell, and the subsequent extreme pain led her to seek out immediate treatment.

Positive Tests, Exams or Signs
Work-up Options
Treatment Options
Treatment Goals
  • Control underlying disease as much as possible
  • Remove necrotic tissue
  • Maintain function
Conservative
  • Urgent treatment is necessary to halt the spread of tissue death as rapidly as possible, and it should be dependent on the specific cause of gangrene
  • An initial conservative approach can provide time for the patient’s condition to stabilize and for the gangrene to become well demarcated1
  • Antibiotics
    • Indicated for gangrene caused by an infection
    • May be administered orally or intravenously, with the latter being appropriate for severe infections or when surgery is needed
  • Intravenous fluid administration
  • Blood transfusion
  • Heparin therapy
  • Hyperbaric oxygen therapy which may be recommended for gangrene caused by bacterial infection
Operative
  • Surgical debridement
    • Necessary in most cases to prevent gangrene from spreading and to allow the surrounding healthy tissue to heal
  • Thrombectomy
    • Should be considered in cases of hand ischemia caused by acute arterial obstruction which can lead to gangrene2
  • Sympathectomy
    • Is sometimes considered if an axillary block with indwelling catheter placement is effective for improving vasodilatation and arterial inflow to the hand2
  • Amputation
    • May be necessary in severe cases when multiple medical conditions and upper extremity venous occlusion are present, when an entire body part (eg, finger, toe, or limb) is affected, and/or when debridement alone is ineffective in controlling the problem1,2
    • Can prevent the spread of gangrene to other parts of the body by removing a necrotic limb.
    • Amputation may need to be done as an emergency in patients with secondary septic shock while cases of dry gangrene maybe treated in a more elective manner.1
  • Reconstructive surgery
    • May consist of a skin graft and/or other techniques
  • Bypass surgery
  • Angioplasty
Complications
  • Septicemia
  • Disability
  • Prolonged wound healing
  • Amputations
  • Death
Outcomes
  • No treatment has been found to be completely effective for gangrene, and early recognition and management is key for increasing the chances of a successful outcome1
Key Educational Points
  • Routine examination of and vigilance towards any early signs of distal ischemia is recommended to prevent symmetric peripheral gangrene from occurring1
  • The long-term management of gangrene secondary to chronic diseases like sclerderma, peripheral vascular disease and/or diabetes should be primarily supportive and symptomatic, and requires coordination via skilled multidisciplinary teams following treatment of the acute problem(s), before surgery is attempted if possible.  In addition, appropriate postoperative care, primary management, and rehabilitation will aslo be needed to assure successful outcomes1
  • Gangrene may be prevented if it is treated before the tissue damage is irreversible; wounds should be treated properly and watched carefully for signs of infection or failure to heal. Those individuals with diabetes or blood vessel disease should routinely examine their extremities for any signs of injury, infection, or change in skin color and seek care as needed
  • In patients that require central or peripheral venous cannulation, multiple cannulation attempts at the same site are not recommended, and ultrasound-guided central venous catheter placement should be used instead when feasible2
  • Hand ischemia treatment following venous occlusive conditions in the upper limb is controversial and only limited experiences are available; in these cases, the limb should be elevated immediately while further treatment options are considered2
References

Cited

  1. Phan PN, Acharya V, Parikh D, Shad A. A rare case of symmetrical four limb gangrene following emergency neurosurgery. Int J Surg Case Rep 2015;16:15-8. PMID: 26406313
  2. Roettges PS, Murray PM, Hill D. Hand gangrene following unsuccessful cannulation of the internal jugular vein: a case report and literature review. Hand (N Y) 2010;5(2):206-9. PMID: 19756870
  3. Goyal RW, Ng AB, Bale RS. Bilateral gas gangrene of the hand - a unique case. Ann R Coll Surg Engl 2003;85(6):408-9. PMID: 14629884
  4. Canale ST, Beatty JH, eds. Campbell's Operative Orthopaedics. 11th ed. Philadelphia, PA: Mosby Elsevier; 2007.
  5. Stevens DL, Bisno AL, Chambers HF, et al. Practice guidelines for the diagnosis and management of skin and soft tissue infections: 2014 update by the infectious diseases society of America. Clin Infect Dis 2014;59(2):147-59. PMID: 24947530
  6. Warkentin TE. Ischemic limb gangrene with pulses. N Engl J Med 2015; 373(7): 642-654. PMID: 26267624

New Articles

  1. Phan PN, Acharya V, Parikh D, Shad A. A rare case of symmetrical four limb gangrene following emergency neurosurgery. Int J Surg Case Rep 2015;16:15-8. PMID: 26406313

Classics

  1. [No authors listed]. Guy's Hospital: Dry Gangrene of the Hand. Prov Med Surg J 1841;1(26):423-6. PMID: 21380038
  2. Solly S. Remarkable case of dry gangrene occurring in a child three years and seven months old. Med Chir Trans 1839;22:253-344.13. PMID: 20895687
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