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Orthopaedics > Other Vascular Conditions > Flashcards

Other Vascular Conditions Flashcards

1
Q

Causes of lower limb ulcers

A

Ulcers - abnormal breaks in skin/ mucous membranes

Majority venous origin 80%
Other causes: arterial insufficiency, diabetic related neuropathy
Rarer: infection, trauma, vasculitis, malignancy (Sqcc)
Less mobile: pressure over bony prominence

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2
Q

Describe venous ulcers and their pathophysiology

A

Shallow, granulated base, other clinical features of venous insufficiency, irregular borders

Medial malleolus classically
Most common leg ulcer

Vascular incompetence/ venous outflow obstruction -> impaired venous return -> hypertension -> trapping WBCs capillaries -> fibrin cuff -> inflammatory mediators -> tissue injury, poor healing, necrosis

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3
Q

Clinical features of venous ulcers

A

Painful (worse end of day)
Often gaiter region

Associated chronic venous disease symptoms (aching, itching, bursting sensation)

Varicose veins
Leg oedema
Venous insufficiency (varicose eczema, thrombophlebitis, haemosiderin, lipodermatosclerosis, atrophie Blanche)

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4
Q

Investigations for venous ulcers

A

Clinical
Venous insufficiency confirmed - duplex USS

Ankle brachial pressure index - assess arterial component, if compression therapy useful

Microbiology swabs + antibiotics if infection

Thrombilia + vasculitis screening young

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5
Q

Management of venous ulcers

A 
Conservative:
Leg elevation 
Exercise 
WL
Nutrition

Antibiotics - evidence infection

Multi component compression bandaging - 30-75% heal after 6months (ABPI >0.6)
Dressings
Emollients

Varicose veins - endovenous or open surgery

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6
Q

Describe an arterial ulcer

A

Distal sites, well defined borders, evidence arterial insufficiency, reduction arterial blood flow, small deep lesions, necrotic base

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7
Q

Clinical features of arterial ulcers

A 
Intermittent claudication 
Critical limb ischaemia (pain night) 
Chronic 
Cold limbs
Thickened nails
Necrotic toes
Hair loss
Reduced pulses
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8
Q

Investigations for arterial ulcers

A

Ankle brachial pressure index
Extent peripheral arterial disease >0.9 normal

Location - duplex USS, Ct angiography, MRA

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9
Q

Management arterial ulcers

A

Critical limb ischaemia - vascular review

Conservative: smoking, WL, exercise

Medical: CVS risks (statin, antiplatelet, Bp, glucose)

Surgical: angioplasty or bypass grafting
Maybe skin reconstruction

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10
Q

Describe a neuropathic ulcer

A

Painless over areas of abnormal pressure, often secondary joint deformity diabetics, a result of peripheral neuropathy, repetitive stress & unnoticed injuries

Punched out appearance

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11
Q

Clinical features of neuropathic ulcers

A

History of peripheral neuropathy or symptoms of peripheral vascular disease

Burning/ tingling legs
Single nerve involvement (mononeuritis multiplex)
Amotrophic neuropathy

Peripheral neuropathy (glove & stocking distribution) 
Warm feet & good pulses
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12
Q

Investigations for neuropathic ulcers

A

Blood glucose levels
Arterial disease - ABPI +/- duplex
Microbiology swab - signs of infection
Deep infection - X-ray

Extend peripheral neuropathy: 10g monofilament or Ipswich touch test + vibration sensation with 128Hz tuning fork

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13
Q

Management of neuropathic ulcers

A 
Diabetic foot clinics 
Diabetic control optimised 
Improved diet 
Exercise 
CVS risk factors 
Chiropody

Infection - antibiotics
Ischaemic/ necrotic - surgical debridement/ amputation

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14
Q

Neuropathic ulcers can be seen alongside Charcot’s foot, what is it?

A

Neuroarthropathy loss joint sensation -> trauma & deformity

Swelling, distortion, pain, loss of function

Loss of transverse arch - rocker bottom sole

Specialist review

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15
Q

How do varicose veins come about?

A

Incompetent valves -> blood flow deep to superficial -> venous hypertension + dilation

98% primary idiopathic
Secondary causes: deep venous thrombosis, pelvic masses, arteriovenous malformations

RFs:
Prolonged standing
Obesity
Pregnancy
FH
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16
Q

What is a saphenous varix & why is it confused with femoral hernias? How can it be identified & managed?

A

Dilation of saphenous vein at saphenofemoral junction in groin
Displays cough impulse (mistaken femoral hernia)
- duplex USS
✅ High saphenous ligation

17
Q

What is the CEAP classification of varicose veins?

A 
Clinical features: 
C0 - no visible/ palpable signs venous disease
C1 - telangiectasia/ reticular veins 
C2 - VV
C3 - oedema
C4a - pigmentation/ eczema
C4b - lipodermatosclerosis / atrophie Blanche 
C5 - healed venous ulcer
C6 - active venous ulcer 
aEtiology:
Ec - congenital
Ep - primary
Es - secondary 
En - no venous cause

Anatomical:
As superficial, Ap perforating, Ad deep, An no venous location identified

Pathophysiology:
Pr reflux, po obstruction, pr,o both, Pn no venous pathophysiology identified

18
Q

Management of varicose veins

A

Non-invasive:
Education
Compression stockings if intervention not appropriate
4 layer bandaging venous ulceration

Surgical: 
If
Symptomatic
Lower limb skin changes
Superficial venous thrombosis
Venous leg ulcer
  • ligation, stripping, avulsion
  • foam sclerotherapy
  • thermal ablation

❌haemorrhage, thrombophlebitis, DVT, disease recurrence, nerve damage

19
Q

What investigation should be performed prior to compression bandaging?

A

Ankle-brachialpreseure index

20
Q

Which term describes tapering of legs (inverted champagne bottle?)

A

Lipodermatosclerosis

21
Q

How does deep venous insufficiency come about?

A

Chronic disease caused by deep venous thrombosis or valvular insufficiency

Failure of venous system (incompetent valves deep venous system)

Primary - defect vein wall/ valvular
Secondary - defect secondary damage

RFs: older, female, pregnant, previous DVT/ phlebitis, obesity, smoking, standing long periods, FH

22
Q

A lady comes in with chronically swollen lower limbs which become achey, pruritic and painful, she sometimes get venous claudication. What do you think is wrong? What May you find on examination?

A

Deep venous insufficiency
Examination: varicose eczema, thrombophlebitis, haemosidderin skin staining, lipodermatosclerosis, atrophie Blanche, venous ulcers

May have post thrombotic syndrome - heaviness, cramps, pain, pruritic, paraesthesia, pretibal oedem, skin induration, hyperpigmentation, venous ectasia, red, ulcers - villalta scale

23
Q

What is atrophie Blanche?

A

Localised round, white atrophie regions surrounded by dilated capillaries

24
Q

Differentials for leg swelling and investigations

A

Deep venous insufficiency - Doppler USS

Renal/ hepatic/ ❤️ disease - FBC, U&Es, LFTs, EChO

25
Q

Management of deep venous insufficiency

A

Conservative
Compression stockings, analgesia, 4 layer bandage ulcers, elevate

Surgical
ValvuLoplasty if symptoms deteriorating
Post thrombotic syndrome with occluded iliac vein - stenting

26
Q

What is thoracic outlet syndrome? Fisk factors?

A

Clinical features that arise from compression of neurovascular bundle within thoracic outlet

  • neurological (nTOS) >95%
  • venous
  • arterial

Women, muscular, middle aged, hyperextensive injuries, repetitive stress (spasm, haemorrhage, swelling scalene), external compressing factors, anatomical abnormalities, clavicular fractures

RFs: trauma, repetitive motion, athletes, anatomical variations

27
Q

Name 3 special tests for thoracic outlet syndrome

A
  • adson’s manoeuvre
    Palapate radial pulse with arm abducted 30dc, turn head look affected shoulder then fully abduct/ extent/ LR - decreases/ loss pulse

Roo’s test - abduct + ER shoulder affected 90dc, bend elbow, open & close hands slowly 3mins - worsening symptoms

Elvey’s test - extend arm 90dc elbow extended & wrist dorsiflexed, tilt ears to each shoulder - loss radial pulse/ worsening symptoms

28
Q

Investigations for thoracic outlet syndrome

A
  • bloods
  • CXR (bony abnormalities e.g. cervical ribs, fracture callus)
  • duplex USS
  • CT
  • venogram
  • Nerve conduction studies
  • MRI
29
Q

Management of TOS

A

Neurogenic - physiotherapy, WL, botulinum toxin A injections

vToS - thrombolysis, anti-coag, venoplasty, venous stent

aTOS (acute limb ischaemia) - urgent vascular input

Surgery:
Decompression (supraclavicular/ transaxillary)

30
Q

A man undergoes a transaxillary surgical decompression for left TOS. Post op he develops dyspnoea, chest is dull to percussion - what is likely diagnosis?

A

Damage to thoracic nerve -> chylothorax

31
Q

What is the term for sweating in XS of that required for regulation of body temp? How is it caused?

A
  • hyperhidrosis
    >6months, once a week+

Increased sympathetic stimulation thoracolumbar autonomic fibres -> eccrine (water) sweat glands (not apocrine oily)

  • primary no underlying cause, often localised, often symmetrical, 1/3 FH, often stop sleep
  • secondary underlying condition e.g. meds, systemic, often generalised
    Causes:
    Pregnancy, menopause, anxiety TB/ HIV/ malaria, malignancy, hyperthyroidism, phaeochromocytoma, carcinoid syndrome, anticholinesterases, antidepressants propranolol
32
Q

Medication and surgical management of XS sweating?

A

Propantheline only anticholinergic agent licensed for use

Surgical: iontophoresis (weak electric current through water soaked sponges)
Botulinum toxin injected (block nerves 2-6months)
Endoscopic thoracic sympathectomy (damage sympathetic ganglion, major op)

33
Q

A patient presents with a sudden onset hot & swollen limb what is most likely? What would your next steps be? How would you manage it once confirmed?

A

Assessment DVT - pain localised calf tenderness/ firmness

History/ FH: pro-thrombotic disease + immobility/ surgery

Well’s score calculated <1 - Doppler USS or D-dimmer
✅LMWH -> long term anticoag

Differentials: cellulitis, MSK infections

Orthopaedics (14 decks)

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