Digital Necrosis: A Hoarder’s Tale

Extreme self-neglect is a problem amongst a small but significant proportion of the population. The hand surgeon encounters cases of acute digital ischemia with a wide spectrum of aetiologies. These include thrombosis, trauma and iatrogenic causes.1 A hoarding disorder is characterised by an individual who acquires an excessive number of items and stores them in a chaotic manner.2 Hoarding is a serious concern to communities and to individuals, causing distress to the individual and those around them and putting both at risk of fire, falls, infection and infestation.2 The condition is particularly challenging to treat, since individuals have little insight of how it is impacting their lives, with extreme self-neglect being a common problem.3-5 We describe a remarkable case of a patient losing their finger due to completely avoidable circumstances, an extraordinary case of finger necrosis following prolonged external compression from a ring in a chronic hoarder. Indeed, the only reason our patient attended hospital was because his sister made a visit to his home and noticed his swollen, and discoloured finger. The patient was a 72-year-old unkempt male presented to the emergency department with a grossly necrotic left little finger. The patient described a four-week history of increasing swelling and discolouration affecting the little finger following a minor injury. On examination, the finger was swollen and necrotic secondary to increasing venous congestion from a tight ring. The whole hand was visibly soiled with the presence of faecal matter under the fingernails. A fifth ray amputation was performed under general anaesthesia preserving the base of the metacarpal and the extensor carpi ulnaris attachment. The patient attended only one follow up appointment, where it was noted that the wound had almost completely healed. Eventually, social services were contacted, due to safeguarding concerns as a vulnerable adult (Figure 1). The rings on the middle and ring finger were removed in the emergency department using ring cutters. Following a thorough intra-operative scrub, a fifth ray amputation was performed under general anaesthesia preserving the base of the metacarpal and the extensor carpi ulnaris attachment (Figure 2A and 2B). Post-operatively, the patient was discharged on oral antibiotics and followed up in the dressing clinic, ten days later. He attended his clinic appointment and was reviewed by the plastic surgery specialist nurse. He appeared unkempt and the dressing had been soiled. On review of the wound, the proximal aspect had healed well, but there was evidence of small area of wound dehiscence and Plastic Surgery Ward, Chelsea and Westminster NHS Foundation Trust, London, UK