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Junior Surgery > Leg Pain And Ulcers > Flashcards

Leg Pain And Ulcers Flashcards

1
Q

What is PVD

A

Peripheral vascular disease
Narrowing or occlusion of the peripheral arteries affecting the blood supply to the lower limbs

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2
Q

Risk factors for PVD

A

Same as for IHD
- age
- smoking
- hypertension
- hyperlipidaemia
- diabetes

Rarely can be due to inflammatory disorders

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3
Q

What is the Fontaine classification and what is it used for

A

Outlines the typical progression of chronic lower limb PAD

  1. Asymptomatic
  2. Intermittent claudication
  3. Ischemic rest pain
  4. Ulceration / gangrene
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4
Q

What is the initial investigation to screen for arterial disease

A

ABPI
Ratio of the BP of the upper arm and lower limb
ABPI <0.8 - arterial disease
ABPI <0.4 - critical limb ischaemia

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5
Q

What does ABPI >1.2 suggest

A

May be a false negative due to calcification giving abnormally stiff vessels
Common in diabetes

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6
Q

Pathophysiology of intermittent claudication

A

Most commonly affects the calf as it is the femoral artery that most commonly becomes atheromatous
Exercise produces an oxygen demand that can’t be met and cold muscles become ischameic
This is relieved on rest

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7
Q

Symptoms of intermittent claudication

A

Ischaemic cramping pain on walking, relieved by rest
Pain reproducible at a similar level
Most commonly in the calf suggesting femoral disease
Pain in the thigh / buttock suggests ileal disease

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8
Q

Signs of intermittent claudication

A

Absent pulses
Cold pale legs
Atrophic hairless and shiny skin - chronic arterial insufficiency
Buerger’s angle <20 degrees
Arterial ulcers

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9
Q

What is ischaemic rest pain indicative of

A

Critical lower limb ischaemia

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10
Q

What is ischaemic rest pain

A

Occurs at night due to decreased effects of gravity and decreased BP reducing perfusion
Pt wakes from pain
Severe pain in forefoot
Can be relived by moving foot or walking on cold floor

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11
Q

What does ischaemic rest pain lead to

A

Ulcers from minor injuries as healing is impaired and if these get infected can lead to rapidly spreading gangrene

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12
Q

What is wet gangrene

A

Infected with proliferating organisms
Moist appearance, gross swelling and blistering

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13
Q

What is dry gangrene

A

Colonised but organisms are not proliferating
Hard, dry texture occurring in the distal toes and gingers
Often a clear demarcation between visible and black necrotic tissue

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14
Q

Management of wet gangrene

A

Is a surgical emergency
Requires urgent debridement to control spreading infection
Broad spectrum IV abx

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15
Q

What does presence of gangrene suggest

A

Threatened limb
ABPI <0.4
Requires surgical intervention

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16
Q

Conservative Management of PVD

A

Generally conservative
- smoking cessation, weight loss, exercise
- orthotics - raiding heel of shoe to decrease calf work
- foot care to prevent minor trauma
- optimise BP: avoid B blockers and diabetes

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17
Q

Medical management of PVD

A

Antiplatelet (clopidogrel) and statin
Management of diabetes

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18
Q

Surgical management of PVD (used if ABPI <0.6 or conservative insufficient)

A

Percutaneous transluminal angioplasty
- arterial catheter guided from femoral artery to diseased area and balloon inflated in narrowed segments
- effective for short segments of stenosis but risky

Bypass grafting
- for longer segments

Sympathectomy
- pain relief

Amputation

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19
Q

Risks of percutaneous transluminal angioplasty

A
  • emboli formation and distal ischaemia
  • iatrogenic arterial dissection
  • anaphylaxis to contrast medium used
  • AKI secondary to contrast medium used
  • haemorrhage
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20
Q

Benefits of amputation

A

May relieve intractable pain and prevent death from septicaemia

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21
Q

How to prevent phantom leg pain

A

Start neuropathic pain agent eg gabapentin pre amputation

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22
Q

Causes of an acutely ischaemic limb

A

Thrombus - rupture of atherosclerotic plaque leads to platelet aggregation and acute thrombosis
Embolus
Trauma

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23
Q

Predispositions for thrombosis (virchows triad)

A
  1. Endothelial dysfunction (trauma, inflammation, atheroma)
  2. Changes in blood flow: stasis or slow flow
  3. Changes in blood coagulability: inflammatory response / congenital causes
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24
Q

What is embolic occlusion

A

Occlusion of a vessel by a mass of material transported in the bloodstream
- usually a fragment of a thrombus

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25
Q

Where can thromboemboli arise from

A

Left atrium in AF
Left ventricle post MI
Heart valves in endocarditis
Aorta in AAA

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26
Q

Clinical symptoms of acutely ischaemic limb (6P’s)

A

Pulseless
Painful
Pallor
Perishingly cold
Paralysis
Paraesthesia

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27
Q

Clinical features of an embolus

A

Sudden onset
Very Severe symptoms due to lack of collaterals
Normally an identifiable source eg AF or AAA
Normal pulse history
No history of arterial disease

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28
Q

Clinical features of a thrombosis

A

Insidious onset
Less severe symptoms as advanced collaterals
No obvious source
Long standing decreased pulses bilaterally
Previous history of IC, stroke, MI etc

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29
Q

Management of acutely ischaemic limb

A

Max 6hrs to re-establish flow
A-E resus
IV heparin
Assessment of limb:
- no blood supply = surgery
- if obstruction is resolving = thrombolysis

Urgent CT angiogram
If leg is not thought to be viable, amputation may be only treatment option

30
Q

Embolic occlusion in acutely ischaemic limb management

A

Open embolectomy
Interval investigation into the underlying cause eg AF / AAA

31
Q

Thrombotic occlusion management in the acutely ischaemic limb

A

Intra-arterial thrombolysis to restore vessel patency
Interval angioplasty to treat underlying disease

32
Q

Presentation of diabetic peripheral vascular disease

A

Sensory neuropathy - reduces protective reactions to minor injuries and reduces awareness of symptoms of infection / ischaemia

Autonomic neuropathy - lack of sweating leads to dry, fissured skin allowing entry of bacteria

Motor neuropathy - wasting of the small muscles of the foot lead to loss of the arches and development of abnormal pressure areas

Red and hot with strong pulses

33
Q

Transfemoral and transtibial leg amputations

A

Transfemoral = above knee
Transtibial = below knee

34
Q

Goal of lower limb amputation

A

Amputate at the most distal level that will remove the diseased tissue but preserve residual limb length creating best environment for return of mobility and function

35
Q

Outcome of Transfemoral amputation vs transtibial

A

70% of trans-tibial amputees will walk
40% of trans-femoral

36
Q

Complications of lower limb amputation

A

Non healing stump wound
- occurs if amputation is too distal and underlying disease is still active

Stump pain

Phantom pain
- occurs in 55-85%

Psychological
- 75% experience low mood / anxiety

37
Q

What does suitability for prosthetic rehabilitation depend on

A

Cognitive ability
Motivation
Expectation
Goals
Physical strength
Co-morbidities

38
Q

Associated complications of lower limb amputation

A

Pressure sores
Skin rashes
Allergies
Neuroma development
Contralateral joint issues
Poor patient acceptance

39
Q

What is the difference between the superficial and deep venous systems

A

Deep venous system comprises a number of veins that accompany the major lower limb arteries - drains the muscular compartment of the leg

Superficial venous system comprises the medial long saphenous vein which drains to the saphenofemoral junction and the lateral short saphenous which drains popliteal vein - drains the skin and superficial tissues

40
Q

Where do the deep and superficial venous systems join

A

Saphenofemoral and saphenopopliteal junction

41
Q

Define varicose veins

A

Abnormally dilated and lengthened superficial veins

42
Q

Pathophysiology of varicose veins

A

Valvular insufficiency in the superficial veins leads to primary varicose veins whereas valvular insufficiency in the deep veins leads to deep venous insufficiency and secondary varicose veins

43
Q

What are primary varicose veins

A

2x as common in women with pregnancy accentuating symptoms
Likely due to primary superficial valve defect with familial elements
Surgical treatment possible

44
Q

What are secondary varicose veins

A

Superficial varicosities develop secondary to deep venous insufficiency
- calf pump can no longer efficiently return blood to the thoracic cavity due to valve failure in the deep venous system
- high pressure in deep venous system leads to perforator vein incompetence and resultant back flow to superficial venous system

45
Q

Causes of secondary varicose veins

A

Previous DVT as valves remain incompetent
Raised systemic venous pressure - due to large vein compression, arterio-venous fistula or severe tricuspid incompetence
Congenital absence of valves (rare)

46
Q

Clinical features of deep venous insufficiency

A
  • lower limb aching pain / discomfort
  • oedema of lower leg
  • superficial varicose veins
  • haemosiderin deposition in gaiter area
  • eczema / pruritis
  • atrophie blanche
  • lipodermatosclerosis - inverted champagne bottle
  • ulceration
47
Q

Symptoms of varicose veins

A

Unsightly appearance
Itching
Nocturnal cramps
Oedema of ankles
Dull ache to leg
Signs of deep venous insufficiency

48
Q

Investigations for varicose veins

A

Hand held Doppler
- identifies reflux at saphenofemoral / saphenopopliteal junctions

Duplex scanning
- can diagnoses valvular and perforation vein incompetence as well as large vein occlusion
- can confirm deep venous insufficiency

Venography
- contrast injected into superficial vein of foot. Fluoroscopy used to see progress through deep vein system

49
Q

Management of varicose veins

A

Avoid prolonged standing, exercise, weight loss

Graded compression stockings - first exclude arterial disease with ABPI

If dilated, haemorrhage, deep venous insufficiency then consider:
- endothermal ablation
- sclerotherapy
- surgery

50
Q

What is endothermal ablation for varicose veins

A

Laser fibre passed along the vein (USS guided)
And then fired to cause heat and endothelial ablation leading to vein thrombosis

51
Q

What is sclerotherapy for varicose veins

A

Used for cosmetically undesirable varicosities
Chemical sclerosant injected into an empty vein and the vein is kept compressed for 2 weeks to allow fibrosis to take place

52
Q

Describe surgery for varicose veins

A

Gold standard
- great saphenous vein is disconnected from the femoral vein
- any incompetent perforators are individually ligated

53
Q

Complications of varicose veins

A

Haemorrhage: caused by minor trauma to a dilated vein
Phlebitis: can occur spontaneously or following sclerotherapy
- veins become hard and tender with overlying erythema
- may be systemic upset

54
Q

What is lymphoedema

A

Progressive disorder of the lymphatic system that results in accumulation of interstital fluid and fibroadipose tissue
Blockage to normal lymphatic drainage routes cause chronic non pitting oedema

55
Q

How to differentiate between intermittent claudication and spinal claudication

A

Intermittent is worse walking uphill
Spinal would be worse walking down hill

56
Q

What is primary lymphoedema

A

Presents in early life
Secondary to an inherited deficiency of lymphatic vessels
Most commonly affects the legs and progresses with age

57
Q

What is secondary lymphoedema

A

Obstruction of lymphatic vessels
Usually due to malignancy or cancer related therapy eg radiotherapy or lymph node dissection

58
Q

Diagnosis of lymphoedema

A

Usually clinical after other causes of oedema have been excluded eg CCF, renal disease, deep venous insufficiency
Specialist centres can use lymphoscintigraphy

59
Q

Management of lymphoedema

A

Elevation of limb
Compression stocking
Physical massage
Long term abx for recurrent cellulitis

60
Q

What is Raynaud’s phenomenon

A

Episodic digital vasospasm in the absence of an identifiable associated disorder
Most commonly presents in 15-30 year old females with FH
Thought to be an exaggerated response of the physiological vasospasm process

Brought on by cold or emotional stress

61
Q

What are the 3 phases of Raynaud’s phenomenon

A
  1. Pallor: due to digital artery spasm
  2. Cyanosis: due to accumulation of deoxygenated blood
  3. Rubor: erythema due to reactive hyperaemia
62
Q

What is raynaud’s syndrome

A

Raynaud’s phenomenon secondary to another condition that causes peripheral vasospasm

63
Q

What conditions can cause peripheral vasospasm

A

Connective tissue disorders:
- systemic sclerosis, SLE, sjorgens syndrome, polyarteritis nodosa

Macrovascular disease
- atherosclerosis, thoracic outlet obstruction, buerger’s disease

Occupational trauma
- vibration white finger, repeated extreme cold or chemical exposure

Drugs:
- B blockers or cytotoxic drugs

Others:
- malignancy, AVF

64
Q

What is venous duplex US used for

A

Is the investigation of choice for varicose veins / chronic venous disease
- shows retrograde venous flow

65
Q

Management of peripheral arterial disease

A

Clopidogrel 75mg
Atorvastatin 80mg

66
Q

Clinical features of venous ulcers

A

Brown pigmentation
Lipodermatosclerosis (champagne bottle legs)
Eczema

67
Q

ABPI value for critical limb ischaemia

A

0.3

68
Q

ABPI value for hyperaemia and severe vascular disease

A

0.5

69
Q

Management for superficial thrombophlebitis

A

Compression stockings
(If arterial insufficiency has been excluded)

70
Q

What is the screening programme for AAA

A

Single abdominal ultrasound for males aged 65

Junior Surgery (6 decks)

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