Non-traumatic leg pain Flashcards
What is an acutely ischaemic leg?
Where an acute arterial occlusion occurs in a previously normal limb
The features of ischaemia are increased because of the absence of a developed collateral circulation
What are the common symptoms of acute leg ischaemia?
6 Ps: Pain Paraesthesia Pallor Pulseless Paralysis Perishingly cold
How can you differentiate between embolic or thrombotic causes of acute leg ischaemia?
Embolic cause - normal pulses in contralateral limb
Thrombotic cause - absent pulses in contralateral limb
What are some signs of chronic vascular insufficiency?
Muscle wasting
Hair loss
Ulceration
What is the management for acute leg ischaemia?
Urgent angioplasty within 6 hours to avoid necrosis
Thrombolysis with tissue plasminogen activator (tPA) - most effective when given via local arterial catheter
Anticoagulation with heparin
Analgesia - IV opioid
What are the complications of acute leg ischaemia?
Need for amputation
Rhabdomyolysis
Renal failure
What organisms typically cause cellulitis?
Usually streptococcal
Occasionally staphylococcal
What are the risk factors for cellulitis?
Diabetes Immunocompromised Steroid use IVDU Obesity Alcoholics
How does cellulitis present?
Painful, swollen, erythematous, warm area
Poorly defined margins
Lymphadenopathy
Systemic symptoms e.g. fever
What anaerobic organism can cause cellulitis? What sign is indicative of this?
Clostridium perfringens
Crepitus
How do you treat cellulitis?
Abx for 7 days PO (admit and give IV if severe)
Flucloxacillin
Give phenoxymethylpenicillin or benzylpenicillin if strep confirmed
Erythromycin if penicillin allergic
What complications can occur with orbital cellulits?
Blindness
Meningitis
Cavernous sinus thrombosis
What does the leg look like in a DVT?
Red, hot, swollen calf or thigh
Distention of superficial veins
Pain and tenderness
What are the main risk factors for DVT?
Recent surgery especially orthopaedic, abdominal, spinal, obstetric Recent hospital admission Current malignancy Being bed bound Long haul flights Sepsis IVDU Previous DVT/PE Thrombophilia FH of VTE Pregnancy Synthetic oestrogen
What is the name of the diagnostic score for DVT?
Well’s diagnostic algorithm
Clinical features that scores points:
- Active cancer
- Paralysis or recent plaster immobilisation of the leg
- Recent major surgery
- Local tenderness along distribution of deep venous system
- Entire leg swollen
- Calf swelling >3cm
- Pitting oedema
- Collateral superficial veins (non-varicose)
- Previous DVT
What investigations can you do for suspected DVT?
D-dimer if Wells Score <3 - if negative = unlikely DVT
If D-dimer normal AND Wells score <3 = rule out DVT
If pregnant or IVDU – always USS
If Wells >3 and D-dimer raised - USS
What are the signs of PE?
Tachycardia
Hypoxia
Tachypnoea
Breathlessness
What is the treatment for DVT/
LMWH
Tinzaparin or enoxaparin
1.5mg/kg/24hours
Compression stockings
What is the mechanism of action of LMWH?
Heparins bind to antithrombin which accelerates inhibition of Factor Xa
What is gout?
Disorder of purine metabolism characterised by:
- Raised uric acid level in blood
- Deposition of urate crystals in joints and other tissues
What joints are most commonly affected in gout?
MTP joint of big toe
Knee
What can precipitate gout?
Either intake of too many purines or poor excretion
Increased dietary purines (meat, alcohol) High BMI Thiazide diuretics Renal failure Trauma Infection Genetics
What is important to ask about in the history of someone presenting with ?gout?
Any history of renal stones
How does gouty arthritis present?
Rapid onset Very painful joint Warm, red, swollen joint Shiny skin Attacks last for 1-2 weeks before self-resolving
What investigations can be done to diagnose gout?
Bloods - increased serum urate in 60%, high WCC
Joint aspiration - negatively birefringent crystals, also do cultures to exclude septic arthritis
XRay - soft tissue swelling first, then punched out lesions in peri-articular bone
What is the onset of pain in gout compared to septic arthritis?
Gout - 3-12 hours
Septic arthritis - 1-2 hours
What is the acute management for an attack of gout?
First line = NSAIDs
Second line = Colchicine
What is the mechanism of action of colchicine?
It interrupts the cycle of urate crystal deposition in joints
What is the prophylactic treatment for gout? What class of drug is it? When should you not give it?
Allopurinol = xanthine-oxidase inhibitor
Do not give in acute attack of gout
What joint is most commonly affected by septic arthritis?
Knee
What group of patients might have involvement of uncommon joints in septic arthritis?
IVDU
What organisms most commonly cause septic arthritis?
Staph aureus = 70%
Streptococci
Neisseria gonorrhoea
E. Coli
What organism causes septic arthritis in prosthetic joints?
Coagulase negative staphylococci
How does septic arthritis typically present?
Typically only 1 joint affected
Red, painful, swollen
Intolerant of any movement
Systemically unwell
What are the main risk factors for septic arthritis?
Immunosuppression Diabetes Prosthetic joints IVDU Rheumatoid arthritis
How do you diagnose septic arthritis?
Joint aspiration - yellow, purulent, WCC > 10,000, neutrophils
Bloods - cultures, ESR, WCC, CRP
What might be seen on X-Ray of septic arthritis?
May be normal initially or show only soft tissue swelling with displacement of capsular flat planes
Later - features of bone destruction and wider joint space
How do you treat septic arthritis?
IV Benzylpenicillin and flucloxacillin for 2 weeks then PO for 4 weeks
If penicillin allergic - clindamycin
If MRSA suspected - vancomycin
If gonococcal/E. Coli - cefotaxime
