Case Reports Indian Pediatrics 2005; 42:1156-1158 |
||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Neonatal Lower Extremity Gangrene |
||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
From the Department of Pediatric Surgery, LTMMG and General Hospital, Sion, Mumbai 400 002, India. Correspondence to: Dr Paras R Kothari, Lecturer,
Department of Pediatric Surgery, L.T.M. Medical College and General
Hospital, Sion, Mumbai 400 022, India.
Bilateral lower limb gangrene in neonates is a rare event of obscure etiology. It generally has a poor outcome. Early diagnosis and properly timed intervention may help in some cases where the etiology is known. Idiopathic gangrene with delayed treatment poses a challenge to Paediatric surgeons, as it is associated with increased morbidity and mortality. Case Report Table I details the clinical presentation,
investigations, treatment, and outcome in four neonates with gangrene of
both lower limbs. Table I
Mothers of all these babies had received immunization at proper time. Antenatal sonography although done in later stages of pregnancies in all the mothers had revealed no abnormalities. None of the mothers were diabetic nor anyone had prolonged labour. Three neonates were initially managed by giving intravenous antibiotics, flow enhancers, (heparin, vasodilators, lomodex, hyper baric oxygen, etc.) blood transfusions and regular dressings. Wounds were regularly cleansed by hydrogen peroxide. Eusol and salutyl ointment were used as slough removers. Local ointments like betadine and soframycin were used for regular dressings. Dry dressing was applied over gangrenous area. Inspite of conservative management for two weeks, ischemia progressed to form gangrene; line of demarcation appeared so formal amputations were done. Neonate with exposed bones was operated upon immediately; as to cover them with flaps was impossible. All four neonates had a smooth post-operative recovery. Discussion Bilateral idiopathic lower limb gangrene in neonates is extremely rare and very few cases have been recorded. Predisposing factors include prematurity hyper-coagulable state, umbilical artery cannulation, arterial thrombosis, intravenous hyperosmolar infusions, sepsis, thermal abnormality, in utero arterial thrombosis and maternal diabetes(1-3). Abnormal fetal presentation can cause ischemia due to direct compression of an extremity in utero(1). Arterial occlusion due to normal obliteration of ductus arteriosus or umbilical arteries can lead to high incidence of gangrene in lower extremities(4). However, review of the available literature reveals that upper limb gangrene is more frequent as compared to lower limbs(1-5). Management includes giving medications (systemic and
local) and supportive care like heparin, vasodilators, lomodex,
hyperbaric oxygen, sympathectomy, preventing trauma and sepsis(1, 2).
Early surgical intervention is indicated in presence of severe or
progressive ischemic changes. More often there has been progression to
spontaneous slough or autoamputation(3). Amputation was done following
appearance of demarcation line. Care was taken to preserve the growing
epiphyseal end so as to achieve a good stump length for prosthetic
fitting in the later age. A high index of suspicion and timely treatment
is highly decisive in treating septicemia in neonates(5). | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
References | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
|