Atraumatic leg pain 1 Flashcards
What is the most common of acutely ischaemic leg?
Thrombus - 40% of the cases Emboli - 38% Angioplasty occlusion 15% Trauma Compartment syndrome - rare
What is the symptoms of acutely ischaemic leg
6 Ps
Pale Pain Pulseless Paraesthetic Paralysed Perishingly cold
What other differentials can lead to mis-diagnosis of acutely ischaemic leg?
Cellulitis
Gout
Examination of the acutely ischaemic leg?
A full cardiovascular examination
- cardio exam for heart valve disease due to embolus damage
- abdo exam for aneurysm
- peripheral vascular examination
Try to identify all 6 Ps
What is the classification used to classify ischaemic leg?
Rutherford classification
Classified into viable threatened (salvageable if treated) Threatened (salvageable with immediate reconstruction) Irreversible
It looks into capillary return, motor(paralysis), sensory(paraesthetia), arterial Doppler signal, venous Doppler signal
Ix of acutely ischaemic leg
ECG - identity cardiac arrhythmia or an acute cardiac event - source of emboli
Bloods
- FBC - haematological disorder predisposing to thrombus
- U + E - check K+ which can be raised if muscle necrosis has occurred
- glucose - diabetes (RF)
- creatinine kinase - raised in muscle necrosis
- clotting - clotting disorders - check before prescribing heparin
- G+S - for surgery
ABG - may show acidosis secondary to ischaemia
Imaging - angiograms, MR angiography or CT angiography
management of acutely ischaemic leg
analgesia - IV morphine
oxygen
heparin 5000 units (IV unfractioned) to prevent propagation of thrombosis
IV fluids - avoid Hartmann’s due to potassium
refer to vascular surgeons
what is cellulitis
it is an acute-spreading bacterial infection of the dermis and subcut tissue
usually there is a wound, ulcer or dermatitis
what are the common pathogen of cellulitis?
strep pneumoniae
H.influenza (in paeds)
Gram-ce baccili
anaeorbes
symptoms of cellulitis
rubor - erytherma
dolor - pain
tumor - swelling
calor - heat
systemic effect - fever, malaise, nausea, rigors
confusion in elderly
examination finding of the cellulitis?
peripheral vascular examination to rule out other DCT
normal obs
Ix for cellulitis
primary care - clinical diagnosis
secondary
- bloods - raised WCC, CRP, fasting blood glucose, lipids and cholesterol
- blood culture
- X-ray, CT/MRI if there are any concern of underlying infection
management of cellulitis
general management
- elevate leg
- analgesia
- treatment for tetanus vaccination
ABX
- if minor - PO flucloxacillin or erythromycin (if allergy to penicillin)
if severe - IV flucloxacillin, clindamycin IV (if allergic)
prognosis of cellulitis
usually recovers nicely
recurrent cellulitis in 11-16%
cause of deep vein thrombosis
influence to the Virchow’s triad
- stasis
- hypercoagulopathy
- vessel wall injury/atherosclerosis
blood clot in the deep vein of the leg
what is the risk of DVT
2.5-5% lifetime risks
what is the symptoms of DVT?
pain - unilateral most likely
fever
unilateral pitting oedema
erythema of the affected calf area
local tenderness
50% of pt present with SOB (PE until proven otherwise)
examination findings of DVT
- > 3 treat as a DVT – preform a USS to confirm, D-dimer used to risk stratify
- 1-2 – do a d-dimer if -ve then sufficient to rule out DVT, +ve – USS scan, consider LMWH
- 0 – do a D-Dimer test. If negative then DVT is unlikely. If positive then treat as DVT and do a compression USS to confirm
what are the criteria for well’s score for DVT
total of 10 criteria
1) active cancer - ongoing, last 6 months, palliative
2) immbolisation
3) bedridden > 3 days/major surgery in the last 12 months
4) local tenderness along the deep venous distribution
5) entire leg wollen
6) > 3cm size inc in the affected calf
7) pitting oedema in the affected side
8) collateral superficial vein
9) previous documented DVT
10) other diagnosis as likely as DVT (-2)
Ix for DVT
guided by Well’s score for DVT
USS of calf/leg
d-dimer
calf measurement
ECG for S1Q3T3
venography - dye injected into the foot to visualise blocked vein
management of DVT
to avoid PE - main aim
6 weeks of LMWH - enoxaparin +/- warfarin (3 months [post-op, 6 monthe if no cause, lie-long if recurrent DVT)
can use IVC or do thrombolytic procedure if haemodynacially unstable
what are the different types of crystal arthritis
gout - deposition of urate crystals
psudogout - deposition of calcium pyrophosphate crystal
what birefringent does gout has?
-ve - needle shape
what birefringent does psudogout has?
+Ve - rhomboid shape
aetiology of gout?
high concentration of uric acid in the blood or due to high dietary intake eg meat and alcohol intake
symptoms of gout?
usually monoarthritis
presence of tophi (deposition of urate crystal in the skin)
severe pain that can wake patient up during the night
red hot swollen and tender joint
most patient will have second attack in 18 months
examination of gout?
warm, tender and painful joint
pyrexia - due to the neutrophile acton of trying to engulf the uric acid
urolithiasis in the kidney or bladder - so symptoms of those as well if severe pyelonephritis
Ix of gout
serum urate - will only be raised in 60%
WCC - raised
CRP - raised
synovial fluid - -ve birefreingent and high leukocyte count
X-ray - maybe used in patient with long standing of the gout
management of gout
acute
- analgesia - NSAIDs
- IM/intra-articular steriod
- anti-urate binding agents - colchicine - sued with NSAIDS for analgesia / used when NSAIDs not tolerated
Only allopurinol in chronic treatment to prevent urate acid synthesisby inhibiting xanthene oxidase
what can colchicine cause?
GI upset and NSAID contra-indicated
what is the most common joint to have gout?
MTP
what is septic arthritis
it is bacterial infection of a joint or multiple joints at the same time (which is rare)
what is the most common pathogen that causes septic arthritis
Staph Aureus
what pathogens causes septic arthritis
Staph aureus
rarer causes - N.gonorrhoea
what is the most commonly affected joints due toe septic arthritis
hip then shoulder, ankle and wrist
symptoms to septic arthritis
fever/rigor
red, hot, swollen joints usually only a single joint
pain on movement so people usually try not to move
can have pre-infective injury to the joint
examination of septic arthritis
single, red, hot, swollen joint (can have multiple joints)
Ix of septic arthritis
FBC - WCC raised
CRP - raised
blood culture - often +ve (can lead to speticaemia)
aspirate joint
- synovial fluid for urgent MC+S
- luekocytes raised due to mycobacterial infection
- polarising microscopy to exclude gout
- must be done prior to ABx
Swabs from skins wounds and throat, sputum and urine
management of septic arthritis
flucloxacillin
vancomycin if MRSA
cefuroxime if elderly/recurrent UTI/abdo surgery
