Forearm gangrene following distraction injury at elbow in a neonate.

Gangrene of limbs in newborn is extremely rare. A number of aetiological factors may account for such type of situation. We describe herewith a case of gangrene of forearm in newborn following distraction injury to the physis of elbow and vessels of forearm by excessive pull on upper limb during difficult delivery.

INTRODUCTION

Peripheral ischemia and gangrene of an extremity presenting at birth is a rare clinical entity with a heterogeneous etiology and generally has a poor outcome. In most cases no definite cause has been detected.12 When gangrene is established at birth, surgical amputation, auto-amputation or some loss of function is usual.3 The distraction to an extremity producing physeal and vascular injury following difficult labor secondary to forceful pull on an extremity is extremely rare.5 We present herewith such a case of forearm gangrene.

CASE REPORT

One day old male baby presented to the orthopedics emergency by his parents with bluish discoloration of entire left forearm and hand 12 hours after delivery. The baby was delivered by a trained birth attendant in a village by vaginal delivery but with hand prolapse presentation. The baby was forcibly delivered by the same attendant with vigorous pulling of the hand of the extremity. The baby was pre-term with birth weight of 2.2 kg. The mother never underwent any antenatal checkup. As per statement given by the parents the affected forearm after birth was discolored and the skin temperature was less as compared to normal side 6 h after birth.

On clinical examination after 12 hours of delivery, the bluish discoloration of the extremity from left elbow downwards was noticed. The child was not in shock. His vitals were stable and looked apparently healthy. The affected extremity look longer. A gangrenous patch of 1” × ½” size over the lower end of forearm with ensuing gangrene of all the fingers was seen. The left hand and forearm were noted to be swollen, cool, cyanosed and tip of the fingers were necrosed [Figure 1]. Skin blisters were present on the elbow area. The infant had no spontaneous finger or wrist motion. There was neither any distal pulsation nor any sensation in the hand or forearm and the consistency of forearm was firm to hard. There was no other visible injury in the body.

Figure 1

Clinical photograph (a) Shows longer discolored affected extremity (Left) with cyanosed forearm. (b) Shows line of demarcation at elbow. (c) Clinical photograph showing the ampulation stump

X-ray of the affected extremity including shoulder, elbow and wrist showed a wide gap of 6–7 cm between forearm bones and distal end of humerus [Figure 2]. The humerus and forearm bones appeared normal. A Doppler study of the affected limb revealed absent flow in the forearm distal to the elbow. Routine hematologic investigations including blood sugar estimation were done for the mother of the baby and she was found to be nondiabetic.

Figure 2

X-ray of left arm and forearm (anteroposterior view) shows a wide gap between humerus and forearm bones suggestive of wide separation at physis secondary to distraction

The baby was given parenteral antibiotics to prevent sepsis. After 3 days, a clear-cut demarcation line developed between the gangrenous and healthy area at elbow level [Figure 1b]. Above elbow amputation was done after taking consent from the parents [Figure 1c]. Intraoperatively, it was seen that the lower end of the humerus was separated from the forearm bones at the level of distal humeral physis. The vessels and nerves were found to be stretched out. The postoperative period was uneventful.

DISCUSSION

Gangrene presenting at birth is a rare clinical problem. It results from diminished perfusion of a part of the body, usually the extremities. A variety of etiological factors may account for this situation which include maternal diabetes, arterial thrombosis, emboli, trauma, congenital heart disease, sepsis, coagulopathy, polycythemia, congenital constriction bands, birth trauma, etc.34 Concomitant multiple closed contiguous physeal injuries in a limb along with vascular compromise due to associated distraction-separation type of physeal injury due to road traffic accident have been documented.5

The present case demonstrates an unusual mode of peripheral gangrene in a newborn due to forcible manipulation of the extremity at the time of difficult delivery. The X-ray showing gross separation of forearm from arm at lower humeral physis is quite suggestive of the insult that might have been done to the underlying neurovascular structures. The baby has to undergo amputation once demarcation of the gangrenous area occurred.

Knowledge of the exact sequence of events which lead to the insult and the conditions surrounding it is helpful in determining the etiology and as a consequence the treatment of the lesion. The management of neonatal gangrene is, in general supportive. The close clinical monitoring and prevention of infection of the affected part allows the gangrenous portion to declare itself in order to optimize future reconstruction and rehabilitation.4 Surgical amputation has to be performed in the case of demarcation of necrosis.

The distraction injury to vessels of forearm during delivery leading to gangrene of an extremity is an extremely rare condition. We searched for this rare cause of gangrene in the literature, but could not find it. The present case report assumes significance because of its rarity of occurrence and an unusual presentation.