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Year : 2021  |  Volume : 8  |  Issue : 1  |  Page : 102-104

Missing limb ischemia in dark-skinned patients: The badinjal sign

Division of Surgery, Vascular Surgery Unit, Sultan Qaboos University Hospital, Al-Khoud, Muscat, Oman

Date of Submission26-Apr-2020
Date of Acceptance05-May-2020
Date of Web Publication20-Feb-2021

Correspondence Address:
Edwin Stephen
Division of Surgery, Vascular Surgery Unit, Sultan Qaboos University Hospital, Al-Khoud, Muscat
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/ijves.ijves_45_20

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Limb ischemia is acute, chronic, or acute on chronic, and the prevalence of the latter is rising with the presence of an increasing aging population. When occlusion to the flow of blood is sudden, it results in acute limb ischemia, the early diagnosis of which is vital for the salvage of the limb. In chronic ischemia, the occlusion is progressive, and diagnosis can alter the quality of life for a patient, besides limb salvage. Dark skin tones are more common in Africa, India, Asia, and the Middle East. Diagnosis of limb ischemia is missed in this subset because the classical “pallor” described in Caucasians is not seen. It is seen as shades of duskiness, like the purplish hue on an aubergine – also known as Badinjal, Eggplant, or Brinjal. This article explains why there is a color discrepancy and a need for healthcare professionals to be aware, hence improving limb salvage.

Keywords: Acute, Badinjal, chronic, color, critical, hue, ischemia, limb, salvage, sign, thermography

How to cite this article:
Stephen E, Abdelhady I, Al-Aufi A, Al-Mawaali H, Al-Wahaibi K. Missing limb ischemia in dark-skinned patients: The badinjal sign. Indian J Vasc Endovasc Surg 2021;8:102-4

How to cite this URL:
Stephen E, Abdelhady I, Al-Aufi A, Al-Mawaali H, Al-Wahaibi K. Missing limb ischemia in dark-skinned patients: The badinjal sign. Indian J Vasc Endovasc Surg [serial online] 2021 [cited 2021 Feb 25];8:102-4. Available from:

  Introduction Top

As the aging and diabetic population increases, the prevalence of peripheral arterial disease (PAD) will rise. The overall prevalence of PAD is 3%–10% and reaches 15%–20% in the population above 70 years of age.[1] Acute lower limb ischemia (ALI) constitutes 10%–16% of the work done by a vascular specialist; the distribution per year is 9–16 cases/100,000 persons for the lower limb and 1–3 cases/100,000 persons for the upper limb.[2]

The largest organ in our body is the skin. Its color can reflect one's health, for example, extent of erythema in infection, pallor to assess anemia, and cyanosis for hypoxemia.

Ethnicity and cultural practices pose challenges to the detection of erythema, pallor, hyperemia, and cyanosis, and this socially sensitive issue can lead to missed/misdiagnosis.

The authors noticed a resemblance between the various shades of an aubergine and the hue of the overlying skin of dark-skinned patients who present with acute or chronic limb ischemia, giving rise to the term – “Badinjal sign.”

The objective of this study was to describe a clinical sign which can be useful in the clinical examination of the ischemic limb.

  Case Report Top

Mr. X, a 55-year-old Caucasian smoker with no comorbidities, presented with pain in his left calf on walking. The symptoms had started about 6 months prior, and the walking distance worsened down to 50 m. He had absent pedal pulses on the side; the foot was pale on elevation and hyperemic in dependent position [Figure 1]. He was diagnosed to have chronic limb ischemia.
Figure 1: Hyperemic left foot in dependent position in a Caucasian

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Mrs. Y, a 75-year-old Omani woman, diabetic for 15 years, presented with pain in her right first toe, a tender forefoot, and an inability to sleep. On examination, pedal pulses were absent; the forefoot was dusky (Badinjal sign), tender, and cold to touch [Figure 2]a. Capillary refill was difficult to assess due to the nails being colored with native leaves called “henna” [Figure 2]b. She was admitted for surgical management of critical limb ischemia.
Figure 2: (a) Dusky right forefoot (Badinjal sign). (b) Dusky forefoot with “henna” on the toe nails

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Mr. Z, a 45-year-old Omani patient with underlying end-stage renal disease on dialysis, presented to the emergency department (ED) with sudden-onset pain in his left leg that started 5 hours prior. At a hospital closer to his home, he was given an analgesic. As the pain did not settle, he came to the ED. On examination, he had a dusky hue (Badinjal sign) of the leg, with no popliteal or pedal pulses, and the limb was cold below the knee with reduced movements of the ankle and toes [Figure 3]a. A diagnosis of ALI was made, and the patient underwent a successful emergency popliteal and tibial artery embolectomy.

The dusky hue seen in the second and third cases can be compared to the colors seen on a Badinjal [Figure 3]b.
Figure 3: (a) Acute limb ischemia with a Badinjal sign. (b) Colors on a Badinjal/aubergine/brinjal

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  Discussion Top

In 2010, an article by Baker et al.[3] brought to light the disparity in health care because of race and color. Thereafter, Sommers[4] stressed on the need for “color awareness” while assessing a patient and not being “color blind.”

The inner side of the upper arm gets little or no ultraviolet light (UV) exposure, and the color of the skin is called the “constitutive” color. Exposure to UV leads to an increase in melanin, leading to tanning of the skin and is the “facultative” color.[4] The Fitzpatrick scale of I–VI takes into account the very fair (Type 1) to very dark (Type VI) based on how they sunburn or tan on exposure to sunlight.[5] Age and ethnicity do play a role in skin color and heterogeneity.[6]

Examination of the limb/s should ideally be in natural light or with a halogen lamp, as fluorescent light gives the skin a bluish tint. Dark skin has increased amount of melanin, and this can mask the “blanching response” as the color change would not be visible despite a local change in blood volume.[4] Clinical signs of an ischemic limb such as change in color/temperature/sensation/function, the “6P's,” capillary refill time, venous refill time, and presence of blue toe/s cannot be undermined.

Cultural practices such as the application of “henna” to the upper and lower limbs and nails [Figure 2]b make the assessment of capillary refill nearly impossible.

We propose that a parallel be drawn to the colors on a “Badinjal” when patients with dark skin present with limb ischemia and are examined by health-care personnel. When the limb presents early, the hue is light purplish and if missed, then it becomes a darker purple, as shown in [Figure 3]b. This color awareness is crucial in order to improve the outcomes of limb salvage.

Newer modalities such as smartphone-attached thermography cameras are projected to increase limb salvage at a relatively low cost and do not involve direct patient contact.[7] While awaiting the validation of results on this and other newer technologies, we believe that color awareness has helped us salvage limbs early over the past 2 years.

  Conclusion Top

Color awareness is important and has relevance to outcomes in limb salvage, especially in centers that manage patients with dark skin tones. If the shades on a “Badinjal” can be kept in mind while assessing a patient with or suspected to have limb ischemia, limb salvage rates will improve.


The authors would like to acknowledge Dr. Albert Abhinay Kota, Assistant Professor, Department of vascular surgery, Christian Medical College, Vellore, Tamil Nadu, India, for his critical appraisal of the manuscript..

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patients have given their consent for 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


Conflicts of interest

There are no conflicts of interest.

  References Top

Dua A, Lee CJ. Epidemiology of Peripheral Arterial Disease and Critical Limb Ischemia. Tech Vasc Interv Radiol 2016;19:91-5.  Back to cited text no. 1
Knowles M, Timaran CH. Epidemiology of acute critical limb ischemia. In: Dieter R, Dieter R Jr., Dieter R 3rd, Nanjundappa A, editors. Critical Limb Ischemia. Cham: Springer; 2017. p. 1-7.  Back to cited text no. 2
Baker RB, Fargo JD, Shambley-Ebron D, Sommers MS. A source of healthcare disparity: Race, skin color, and injuries after rape among adolescents and young adults. J Forensic Nurs 2010;6:144-50.  Back to cited text no. 3
Everett JS, Budescu M, Sommers MS. Making sense of skin color in clinical care. Clin Nurs Res 2012;21:495-516.  Back to cited text no. 4
Sachdeva S. Fitzpatrick skin typing: Applications in dermatology. Indian J Dermatol Venereol Leprol 2009;75:93-6.  Back to cited text no. 5
[PUBMED]  [Full text]  
de Rigal J, Des Mazis I?, Diridollou S, Querleux B, Yang G, Leroy F, et al. The effect of age on skin color and color heterogeneity in four ethnic groups. Skin Res Technol 2010;16:168-78.  Back to cited text no. 6
Lin PH, Saines M. Assessment of lower extremity ischemia using smartphone thermographic imaging. J Vasc Surg Cases Innov Tech 2017;3:205-8.  Back to cited text no. 7


  [Figure 1], [Figure 2], [Figure 3]


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