versão On-line ISSN 2309-8309
SA orthop. j. vol.8 no.4 Pretoria Jan. 2009
MN RasoolI; J Pryce-LewisII; R SmitII
IFCS(Orth); Consultant Orthopaedic Surgeon. Department of Orthopaedics, Nelson R Mandela School of Medicine, University of KwaZulu-Natal, Durban
IIMBChB; Registrar. Department of Orthopaedics, Nelson R Mandela School of Medicine, University of KwaZulu-Natal, Durban
Ischaemia of the foot in infants is a cause for concern leading to gangrene, amputation and medicolegal inquiry. The causes of gangrene are usually complicated and multifactorial.1 The gangrene usually develops following a severe bacterial or viral infection. Septicaemia is usually accompanied by dehydration, shock and severe metabolic derangements. Mechanical causes include invasive vascular procedures and venipuncture especially in newborns.
The gangrenous change may imply surgical error especially when the infections occur following surgery or plaster cast immobilisation.
Children who survive these infections are at a higher risk for complex orthopaedic problems later with growth. Involvement of the physeal circulation due especially to bacterial septicaemia may take several years to manifest resulting in longitudinal and transverse growth problems.2 Ischaemic insults to the developing skeleton result in gangrene, skin necrosis and irregularities of epiphysis, metaphysis and physis with premature physeal closure. This may require skin grafting (and later release of contractures), amputation (and later revision of stump) and orthopaedic procedures to address deformity and leg length discrepancy.
It is important for the orthopaedic surgeon to become involved early in the treatment team to decide on fasciotomy, amputation level, prosthetic fitting and anticipated long-term growth problems.
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1. Farrar M.J, Bennet GC, Wilson NL, Azmy A. The orthopaedic implications of peripheral limb ischaemia in infants. J Bone Joint Surg 1996B;930-3. [ Links ]
2. Shehadi SI, Slim MS, Dabbous IA. Gangrene of lower extremities in infants following acute gastroenteritis. Plast Reconstr Surg 1968;42:530-4. [ Links ]
3. Grogan DP, Ogden JA. Chondro-osseous growth abnormalities after meningococcemia. J Bone Joint Surg 1989;71A:920-8. [ Links ]
4. Urbaniak JR, O'Neil MT, Meyer LC. Purpura fulminans. J Bone Joint Surg 1973;55A:69-77. [ Links ]
5. Jacobsen ST, Crawford AH. Amputation following meningococcemia. Clin Orthop 1984;185:214-9. [ Links ]
6. Nogi J. Physeal arrest in purpura fulminans: a report of three cases. J Bone Joint Surg 1989;71A:929-31. [ Links ]
7. Robinow M, Johnson GF, Nanagas MT, Mesghali H. Skeletal lesions following Meningococcemia and disseminated intravascular coagulation. A recognizable skeletal dystrophy. Am J Dis Child 1983;137:279-83. [ Links ]
8. Fernandes F, Pueyo I, Jimenez JR, Vigil E, Guzman A. Epiphyseometaphyseal changes in children after meningococcic sepsis. Am J Radiol 1981;136:1236-8. [ Links ]
9. Bogumill MG. Bilateral above the knee amputations: A complication of chicken pox. J Bone Joint Surg 1965;47A:371-4. [ Links ]
10. Gyde OHB, Beales DI. Gangrene of the digits after chicken pox. Br Med J 1970;4:284-8. [ Links ]
11. Wells KE, Steed DL, Zajko AB, Webster MW. Recognition and treatment of vascular insufficiency from Cafergot. J Vasc Surg 1986;4:8-15. [ Links ]
12. Noyez JF, Sinzobahamvya N, Kalangu K. Peripheral gangrene in African children. A clinical report of 12 cases. Acta Orthop Belgica 1996;62:207-10. [ Links ]
13. Letts M, Blastorah B, Al-Azzam S. Neonatal gangrene of the extremities. Pediatr Orthop 1997;17:397-401. [ Links ]
14. Blank JE, Dormans JP, Davidson RS. Perinatal limb ischaemia. J Pediatr Orthop 1996;16:90-6. [ Links ]
15. Lin PH, Dodson TF, Bush RL, Weiss VJ, Conklin BS, Chen C. Surgical intervention for complications caused by femoral artery catheterization in pediatric patients. J Vasc Surg 2001;34:1071-8. [ Links ]
16. Alpert J, O'Donnell JA, Parsonnet V, Brief DK, Brener BJ, Goldenkranz RJ. Clinically recognized limb ischaemia in the neonate after umbilical arterial catheterization. Am J Surg 1980;140:413-8. [ Links ]
17. Ancora G, Soffriti S, Faldella G. Diffuse and severe ischaemic injury of the extremities: A complication of umbilical vein catheterization. AJ Perinatal 2006;23:341-4. [ Links ]
18. Hootnick Dr, Packard DS, Levinsohn EM, Crider RJ. Congenital arterial abnormalities associated with clubfoot. Clin Orthop 1982;167:160-3. [ Links ]
19. Hootnick DR, Packard DS, Levinsohn EM. Necrosis leading to amputation following clubfoot surgery. Foot Ankle 1990;10:312-6. [ Links ]
20. Davies MV, Nadel S, Habibi P, Levin M, Hunt DM. The orthopaedic management of peripheral ischemia in meningococcal septicaemia in children. J Bone Joint Surg (Br) 2000;82B:383-6. [ Links ]
21. Bache CE, Torode IP. Orthopaedic sequelae of meningococcal septicaemia. J Pediatr Orthop 2006;26:135-9. [ Links ]
Mr MN Rasool
Department of Orthopaedics
Nelson R Mandela School of Medicine
University of KwaZulu-Natal
Private Bag 7
Tel: (031) 260-4297; Fax: (031) 260-4518
This article is the sole work of the authors. No benefits of any form are to be received from a commercial party related directly or indirectly to the subject of this article.