Sunday, April 28, 2013

Neglected Hand . . . Need Help

I need help to manage a patient.

This 45 year old lady came to us with a very bad ulcer of her left wrist. And it is stinking very bad. It seems that there are maggots inside. 

The X-Ray shows dislocation of the metatarsophalangeal and distal interphalangeal joints of the thumb. There appears to be gas gangrene too. 

We tried our best to send them off to a higher centre. They are only willing to go home if nothing can be done here. 

The additional challenge is that she has a hemoglobin of 5 gm%. And an ESR of 150 mm/hr. And no evidence of diabetes. 

My plan is to do an amputation as soon as we get couple of pints of blood. 

Any other choice . . . I would appreciate responses . . . 


  1. We have several such cases in palliative care at Lalitpur, mostly of the foot. So far, no amputation has been needed. Antibiotics, removal of maggots with turpentine oil (a sponge soaked in turp oil and waved over the wound to smoke the maggots out; needed twice a day) and daily dressings with powdered metronidazole (eliminates the odour) has worked for us.

  2. I would definetely clean the maggots ( i am sorry but no idea how to get this done, I am afraid I have not seen that in my carreer) and then surgically clean the wound removing all death tissue. Treatment with metronidazol, a cefalosporin and vancomicin should help. If the gangrene gets worse your only option will be amputation though.

    And she needs a blood transfusion as soon as possible.

    Good luck

  3. The appearance of the fingertips seems to suggest some sort of neuropathy (similar to leprosy) that is causing resorption of the terminal digits. Will ask the hand people here in Vellore about what they think.

    1. Yes it does look like a Hansen affected hand. Placing a surgical pad soaked with a few drops of Ether does get the maggots out. If you can lay open the flexor tendon tract (thumb flexor seems affeted ) under proper tourniquet control , excise the necrotic tendon, and stick to regular dressings along with app antibiotics , padded pop splint and elevation the condition should resolve. THUMB maY need later IP joint fusion.But if is shown to be gas gangrene , more radical approach may be warranted.

  4. Thank you, friends. Unfortunately, the family decided to take a discharge. Not even 24 hours passed since the admission. Quite a common thing here.