A 65-year-old diabetic man presents with a 2-hour history of sudden-onset cold, pale, pulseless, and painful left foot and lower leg. There is mild paraesthesia in the toes but he can flex and extend them. On examination no pulses are palpable below the left femoral pulse. His ECG shows atrial fibrillation. What is the Rutherford classification and the appropriate management?
- A Rutherford IIa (marginally threatened limb); urgent embolectomy or catheter-directed thrombolysis ✓
- B Rutherford I (viable limb); anticoagulation alone and elective revascularisation
- C Rutherford III (irreversible ischaemia); primary amputation
- D Rutherford IIb (immediately threatened limb); emergency embolectomy only
Explanation
Acute limb ischaemia with the '6 Ps' (pain, pallor, pulselessness, paraesthesia, perishingly cold, paralysis) in a patient with AF (suggesting cardioembolism) must be rapidly classified. Preserved motor function with mild sensory deficit but no paralysis classifies this as Rutherford IIa (marginally threatened) — the limb is salvageable with prompt revascularisation. Both emergency surgical embolectomy and catheter-directed thrombolysis are appropriate options for IIa; the choice depends on cause, anatomy, and centre expertise. Rutherford I (no sensory/motor deficit) allows a broader window for planning. IIb involves rest pain and significant sensory loss with motor weakness — requires emergency surgery within hours. Rutherford III (profound paralysis, fixed mottling) mandates primary amputation.
Reference: Bailey & Love's Short Practice of Surgery, 27th ed.
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Written and medically reviewed by the StethoPrep medical team.