Emboli and palpable pulses

A 64-year-old man with type 2 diabetes of 9 years' duration was referred to the diabetic foot clinic by his general practitioner with a painful blue left hallux which did not blanch when digital pressure was applied. He worked as a porter in a meat market and was a heavy smoker who drank up to 14 units of alcohol per day. He denied any trauma to the foot, and his pedal pulses were palpable. X-ray of his foot and ultrasound of his abdomen including the aorta were normal. He was in sinus rhythm and his electrocardiogram (ECG) and echocardiogram were normal.

The toe became necrotic but was not amputated. At first it was believed that the necrosis was full thickness and that the toe would autoamputate through the interpha-langeal joint, but the necrosis was more superficial than first thought. The toe was treated conservatively with outpatient debridement by the podiatrists and systemic antibiotics and aspirin, and healed in 1 year. He continued to smoke heavily despite being referred to the smoking cessation clinic.

Key points

• The source of the emboli was not clearly established. It is likely that emboli arose from the aorta or the proximal circulation of the lower limb. There was no evidence of aortic aneurysm

• Healing of necrotic digits secondary to emboli is usually protracted

• It is important to prevent infection in the necrotic toes

• Antiplatelet therapy should be given to patients with suspected emboli.

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