PMC3350209_01
Clinical findings after admission of the patient, 3 days after the injection.
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fig1
After the last injection, she immediately developed progressing, cyanosis and hypaesthesia pain in her hand (Figure 1).
Digital angiography showing complete blockage of perfusion to the 4th and 5th digits.
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fig2
After immediate admission digital angiography showed a complete blockage of perfusion to her 4th and 5th left fingers (Figure 2). Histological workup of the amputated tissue showed necrotic soft tissue and bone, a mildly active osteomyelitis, and small vessel thrombosis.  Figure 5 shows the result 2 weeks postoperatively.
Demarcated necrosis of the 4th and 5th fingers after 5 weeks.
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fig3
The patient was followed up as an outpatient for a total of 5 weeks during which time the acral areas of the digits progressed into dry necrosis (Figure 3).
Intraoperative view of the amputated 5th finger showing a thrombosed digital artery (circle) with the visible thrombus at the dissected end (arrow).
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fig4
With no further treatment option left, the 4th digit was amputated at the distal middle phalanx and the 5th digit was exarticulated in the distal interphalangeal joint.  Figure 4 shows the intraoperative view of a thrombosed digital artery in the 5th digit.
Amputated fingers after suture removal 2 weeks postoperatively.
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fig5
Histological workup of the amputated tissue showed necrotic soft tissue and bone, a mildly active osteomyelitis, and small vessel thrombosis.  Figure 5 shows the result 2 weeks postoperatively.