47. Leg pain/swelling Flashcards
DVT.
a) Risk factors
b) Clinical features
c) Confusion with cellulitis
a) Hx of VTE, FHx of VTE, smoker, cancer, immobility, high BMI, surgery,
b) Painful, swollen, discoloured, hot, tender
c) May mimic cellulitis, may have DVT with secondary cellulitis, may have cellulitis with secondary DVT
DVT: Wells’ score
a) Criteria (4 PMHx, 5 clinical fx)
b) DVT likely if score is…
a) Score one point for each of the following:
- Previously documented DVT.
- Active cancer (treatment ongoing or within the previous six months, or palliative).
- Recent paralysis, paresis or plaster of the legs.
- Recently bedridden for three days or more, or major surgery within the previous 12 weeks
- Localised tenderness along the distribution of the deep venous system (such as the back of the calf).
- Entire leg is swollen.
- Calf swelling by more than 3 cm compared with the asymptomatic leg (measured 10 cm below the tibial tuberosity).
- Pitting oedema confined to the symptomatic leg.
- Collateral superficial veins (non-varicose).
- Subtract two points if an alternative cause is considered at least as likely as DVT.
b) 2 or more
Note: for Wells’ PE score it is likely if 5 or more
DVT: management
a) DVT likely - Ix
b) DVT unlikely - Ix
c) Reasons for positive D-dimer
d) Management of confirmed DVT
e) Further investigations
a) Leg U/S, and if this is negative D-dimer. If cannot be arranged in 4 hours, treat empirically
b) D-dimer, and if this is positive leg U/S
c) Malignancy, pregnancy, DIC, post-surgery
d) - LMWH/fondaparinux as soon as possible (in renal failure - UFH/reduced dose LMWH) for 5 days or until INR > 2 for at least 24 hours (whichever is longer)
- Warfarin/DOAC within 24 hours of diagnosis and continue for at least 3 months (then reassess)
- If active malignancy, continue LMWH for 6 months and reassess here
e) - Look for obvious cause (eg immobility, surgery)
- If unprovoked DVT:
> Full examination, FBC, urinalysis, CXR
> If these are negative, CT abdo + pelvis (?malignancy)
> Investigate for thrombophilias if FHx of VTE
Leg swelling.
a) Unilateral - causes
b) Bilateral - causes
a) DVT, cellulitis, trauma, lymphoedema
b) CCF, hypoalbuminaemia (protein-losing enteropathy, malnutrition, liver failure), CKD, nephrotic syndrome, medication (e.g. CCB), venous insufficiency, hypothyroidism
Leg swelling: differentials
a) Orthopnoea, paroxysmal nocturnal dyspnoea
b) Diarrhoea or other bowel dysfunction
c) Painful swollen calf
d) Pigmentation
e) Pelvic lymph node resection
a) heart failure.
b) protein-losing enteropathy.
c) deep vein thrombosis or inflammation - eg, cellulitis, osteomyelitis, phlebitis/thrombophlebitis
d) venous insufficiency.
e) lymphoedema
Leg swelling: investigations
a) Bedside
b) Bloods
c) Imaging
a) Urinalysis (kidneys)
b) FBC, CRP (infection, inflammation), UEs (renal), LFTs, D-dimer, clotting, TFTs
c) ECHO, leg U/S
Venous skin changes.
a) red, itchy, scaly, or flaky skin, which may have blisters and crusts on the surface
b) Hardened and thickened red/darker skin on legs; may have inverted champagne bottle appearance
c) White patches over previous venous ulcer
d) Dark blue, brown or black pigmentation
e) Spider-like thin red vessels
f) Prominent veins
a) Varicose/venous eczema (stasis dermatitis)
b) Lipodermatosclerosis
c) Atrophie blanche
d) Haemosiderin deposition
e) Telangiectasia
f) Varicose veins
Management of venous leg disease.
a) Assessment
b) Conservative management
c) Management of flare-ups
a) Pulses and neurology, ABPI, look for ulcers
b) Compression, encourage mobility and weight loss
c) Topical steroid; if infected - fluclox
Peripheral arterial disease.
a) Give the 3 ways it presents
b) Risk factors - 2 main/ others
c) Assessment
d) Diagnosis based on ABPI
a) Acute limb ischaemia, Chronic limb ischaemia (intermittent claudication or critical limb ischaemia)
b) - Smoking and diabetes mellitus
- Age, AF, cholesterol, CHD, HTN, obesity, thrombophilia
c) Vascular examination:
- Inspection - colour, temperature, ulcers, skin changes, atrophy, hair loss
- Palpation - tenderness, CRT, pulses, sensation
- Special tests: Buerger’s test
d) ABPI ratio < 0.9 indicates the presence of peripheral arterial disease, but ABPI > 0.9 does not exclude PAD
Acute limb ischaemia.
a) Clinical features
b) Main differentials
c) Management
a) Sudden onset of leg pain or a sudden deterioration in claudication, associated with: pallor (or cyanosis), pulselessness, perishing cold, paraesthesia or power loss/paralysis.
b) Peripheral neuropathy, compartment syndrome, DVT, cellulitis
c) - Urgent vascular referral
- Pain relief, A-E etc.
- Bedside: ABPI, ECG
- Bloods: FBC, ESR/CRP, UEs/creatinine, glucose, lipids, HbA1c
- Imaging: vascular angiography, ?leg USS
- Primary interventions: endovascular or surgical (endarterectomy, amputation)
- Secondary prevention: clopidogrel, statin, control HTN and diabetes, smoking cessation
Intermittent claudication.
a) Clinical features - classic presentation and other possible presentations
b) Main differentials
c) Management
a) - Progressive development of a cramp-like pain in the calf, thigh or buttock on walking which is relieved by resting; or,
- unexplained foot or leg pain; or,
- non-healing wounds on the lower limb
- Note: not present at rest or altered by position (indicative of critical limb ischaemia)
b) Spinal stenosis (worse walking downhill, relieved by bending forward), peripheral neuropathy, arthritis (hip, knee, foot/ankle)
c) - Conservative: smoking cessation, dietary changes, exercise programme
- Secondary prevention: clopidogrel, statin
- Manage other risks (e.g. HTN, diabetes)
- Revascularisation: angioplasty or bypass surgery
- Symptomatic (if decline surgery): naftidrofuryl oxalate (peripheral vasodilator - improves walking distance)
Critical limb ischaemia.
a) Symptoms and signs
b) Usual cut-off for ABPI in critical limb ischaemia
c) Management
a) - Symptoms: Chronic rest pain, worse at night, may hang leg out of bed, or sleep in a chair to relieve symptoms in the affected foot.
- Signs: dependent rubor, pallor on elevation of the extremity, reduced CRT, absent pulses, skin changes (eg
ischaemic ulcers, non-healing wounds, gangrene).
b) ABPI < 0.5
c) - Urgent vascular referral
- Pain management
- Consideration for revascularisation/ amputation
Acute painful red calf - 3 main differentials to think of
- DVT
- Cellulitis
- Necrotising fasciitis (need a biopsy)
Superficial thrombophlebitis.
a) What is it?
b) Risk factors
c) Features (vs. DVT and cellulitis)
d) Management
a) Inflammation of a vein, then leading to a blood clot forming within it
b) Varicose veins, IV cannulation, previous phlebitis
c) - Superficial vein that is hard, tender, and inflamed
- DVT*: generalised pain, leg swelling, etc.
- Cellulitis: acutely red, painful, hot, swollen, and tender, abscess; fever (note: may be septic thrombophlebitis)
*May co-exist with thrombophlebitis
d) - Rule out DVT (Wells’ DVT score; leg USS/ D-dimer)
- Rule out cellulitis/septic thrombophlebitis (FBC, CRP, septic screen if necessary)
- Conservative: apply a warm moist towel to the affected area, avoid immobility, elevating affected leg
- NSAIDs to reduce pain and inflamamtion
