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 Table of Contents  
CASE REPORT
Year : 2017  |  Volume : 9  |  Issue : 1  |  Page : 53-55

Neonatal lower limb gangrene: Avoidable causes noticed in north-west Nigeria


Department of Surgery, Federal Medical Centre, Birnin Kebbi, Nigeria

Date of Web Publication29-May-2017

Correspondence Address:
Oni Nasiru Salawu
Department of Surgery, Federal Medical Centre, Birnin Kebbi
Nigeria
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jotr.jotr_36_16

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  Abstract 


A gangrenous limb is a dead limb resulting from compromise of the vascular supply to the limb. The gangrenous limb is a source of infection which can lead to septicaemia with eventual mortality of the patient, hence it is an orthopaedic emergency. Limb gangrene is common in orthopaedic practice but rare in neonatal age group. These are two cases of neonate lower limb gangrene, one was following application of tight polythene bag on the leg to protect the local tattoo (LELE ) applied on the foot of a two week old neonate for cosmesis and the second patient was a complication of traditional bone setter (TBS) intervention in a 10 day old neonate. The first patient was offered a knee disarticulation but the parents declined, took her away from the hospital but she was brought back dead to the same hospital two days later. The second patient had left knee disarticulation, sepsis treated and he was discharge home healthy about three weeks later. There is a need to provide an alternative for protection of applied “LELE” especially in the neonatal age group. Awareness need to be increased on the problems caused by traditional bone setters so that their patronage can reduce.

Keywords: Disarticulation, gangrene, neonate


How to cite this article:
Salawu ON. Neonatal lower limb gangrene: Avoidable causes noticed in north-west Nigeria. J Orthop Traumatol Rehabil 2017;9:53-5

How to cite this URL:
Salawu ON. Neonatal lower limb gangrene: Avoidable causes noticed in north-west Nigeria. J Orthop Traumatol Rehabil [serial online] 2017 [cited 2023 Jan 29];9:53-5. Available from: https://www.jotr.in/text.asp?2017/9/1/53/207170




  Introduction Top


Limb gangrene is a common presentation in orthopedic practice in a developing country like Nigeria. It is a major indication for amputation or disarticulation in Nigeria.[1],[2] The identified causes of limb gangrene in the neonates include hypercoagulability, in utero arterial thrombosis, polycythemia, maternal diabetes, congenital band, umbilical arterial cannulation, intravenous hyperosmolar infusion, and idiopathic.[3],[4] While in children and adults, the causes include traditional bonesetter (TBS) gangrene, peripheral vascular disease, animal bites, and intramuscular injections of drugs.[5],[6]

Limb gangrene is a common cause of mortality if there is delay in treatment because the dead limb will serve as a focus for sepsis which can eventually kill the patient, amputation of the dead part is the treatment for a gangrenous limb, the site of the amputation should be a point where all the dead part of the limb can be removed completely. This is a major cause of disability in a developing country where postoperative rehabilitation is poor and prosthesis is not readily available or avoidable.[7]


  Case Reports Top


Case report 1

A 2-week-old female neonate in a village in the North-West part of Nigeria was brought to the Federal Medical Centre, Birnin Kebbi, by the parents on account of progressive darkish discoloration of her right foot and leg of about 6 days' duration.

The baby had application of local tattoo (LELE) on all her limbs a day before her naming ceremony which is the usual cultural practice in the region. Polythene nylon was wrapped over the tattoo to protect it from being erased. Few hours later, her mother noticed that the nylon on the right lower limb was loose and she retightened it firmly over the baby's leg to prevent the nylon from fallen off. About 4 h, she noticed that the child was crying excessively and she was restless; she was then advised to remove all the polythene nylon used to cover the limbs. Starting from the 2nd day, the baby was noticed to be having progressive right lower limb swelling and progressive darkish discoloration of the skin over the leg. There was also associated low-grade fever and gangrenous right foot up to the mid-leg [Figure 1] and [Figure 2].
Figure 1: Gangrenous right leg

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Figure 2: Gangrenous right leg, anterior view

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Septicemia was diagnosed for the patient following the right foot and leg gangrene.

The patient was commenced on intravenous antibiotics and analgesic, and her parents were counseled for right knee disarticulation for the baby, but they refused the treatment and they eventually signed against medical advice and took the baby away from the hospital. They presented the baby 2 days later, but she had already died as the time they entered the hospital emergency unit.

Case report 2

A 10-day-old male neonate was brought to the Accident and Emergency Unit of Federal Medical Centre, Birnin Kebbi, with gangrene of the left leg. A few days after birth, the baby was noticed not to be moving the left leg like the right; he was then taken to TBS where tight splint was applied; after the 2nd day, progressive darkening of the limb was noticed and the leg was swollen. The splint was removed at home by the parents, and the child was brought to the hospital. At presentation, the child was febrile, jaundiced with left leg gangrene up to the proximal third of the leg [Figure 3].
Figure 3: Gangrenous left legwas

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Septicemia was diagnosed for the child from left leg gangrene.

The child had left knee disarticulation [Figure 4], phototherapy, antibiotics, and analgesics. He was discharged home 3 weeks after the surgery.
Figure 4: Left lower limb after knee disarticulation

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  Discussion Top


Stigmatization and lack of appropriate prosthesis in a developing country has made it difficult for most patients to consent for amputation.[7] Poverty and illiteracy also contribute to patients not giving consent to amputation. Some patients believe that it is better to die with their whole body intact than to have amputation to save their life.

Application of local tattoo to the hand and foot is a common cultural practice in northern Nigeria so as to add more beauty to their look. This practice has also been extended to their neonates, especially in preparation for naming ceremony. The tattoo itself has not been reported to be hazardous, but the tight application of polythene nylon in the reported case is what causes the tourniquet effect on the limb that eventually led to the limb gangrene.

Many patients prefer the treatment of TBS to those of orthopedic surgeons in managing trauma and orthopedic pathology, the reasons adduce to this include that they believe TBS are cheaper, they believe that every pathology has spiritual components which can be taken care by the TBS, fear of amputation, and the fact that those TBSs are members of the same community where the patients reside, hence they are more familiar with them.[8],[9] These are the reasons why most patients including the reported case discharge themselves against medical advice. But, on the contrary to their belief, a lot of life-threatening complications have been reported from TBS management.[5],[10]

The causes of limb gangrene in the first and second patient presented were application of tight fitted materials to the lower limb of these patients by parent and TBS respectively. Despite the level of septicaemia presented by the second patient, his life was saved because they comply with medical treatment. The removal of a dead part of the limb is an important and inevitable step in treating a patient with gangrenous limb. Although it is a serious morbidity to lose a limb, especially in a developing country like Nigeria, it is still better to lose a limb than to lose a life.


  Conclusion Top


Prolonged application of tight fitting materials on the limbs gives tourniquet effect which eventually leads to limb gangrene. This must be avoided especially in neonatal or pediatric age groups, in which they may not have the power to remove it or may be afraid to remove it when they are uncomfortable with the tightened materials.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Onyemaechi NO, Oche IJ, Popoola SO, Ahaotu FN, Elachi IC. Aetiological factors in limb amputation: The changing pattern. Niger J Orthop Trauma 2012;11:79-83.  Back to cited text no. 1
    
2.
Mamuda AA, Salihu MN, Abubakar MK, Adamu KM, Ibrahim M, Musa MU. Profile of amputations in National Orthopaedic Hospital, Dala Kano. Open J Orthop 2014;4:200-4.  Back to cited text no. 2
    
3.
Dare CI, Clarke NM. Neonatal gangrene and amputation. In: Rannie JM, editor. Rannie and Roberton's Textbook of Neonatology. Philadelphia: Churchill Livingstone; 2012. p. 968.  Back to cited text no. 3
    
4.
Singh J, Rattan KN, Gathwala G, Kadian YS. Idiopathic unilateral lower limb gangrene in a neonate. Indian J Dermatol 2011;56:747-8.  Back to cited text no. 4
[PUBMED]  [Full text]  
5.
Nwadiaro HC. Bone setters' gangrene. Niger J Med 2007;16:8-10.  Back to cited text no. 5
    
6.
Hajong R. Upper limb gangrene following intramuscular diclofenac: A rare side effect. J Surg Case Rep 2013;2013. pii: Rjs039.  Back to cited text no. 6
    
7.
Edomwonyi EO, Onuminya JE. An update on major lower limb amputation in Nigeria. J Dent Med Sci 2014;13:90-6.  Back to cited text no. 7
    
8.
Dada AA, Yinusa W, Giwa SO. Review of the practice of traditional bone setting in Nigeria. Afr Health Sci 2011;11:262-5.  Back to cited text no. 8
    
9.
Agarwal A, Agarwal R. The practice and tradition of bonesetting. Educ Health (Abingdon) 2010;23:225.  Back to cited text no. 9
    
10.
Omololu B, Ogunlade SO, Alonge TO. The complications seen from the treatment by traditional bonesetters. West Afr J Med 2002;21:335-7.  Back to cited text no. 10
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4]


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