SM_248a: Limb Vasculature: Clinical Cases Flashcards
Axillary artery is called the ____ above teres major and the ____ below teres major
Axillary artery is called the axillary artery above teres major and the brachial artery below teres major
Describe the Roos test
Roos test
- Used to test for thoracic outlet syndrome: sensitive, not specific
- Open and close fists for minimum of two minutes
- Encourage patient to report any symptoms: pain, fatigue, numbness, tingling
Describe thoracic outlet syndrome
Thoracic outlet syndrome
- Can affect structures such as brachial plexus, subclavian artery, and subclavian vein
- Compression of the area causes a constellation of distinct symptoms: upper extremity pallor, parasthesia, weakness, muscle atrophy, and pain
- Compression of nerve roots most often occurs within the interscalene triangle but can also occur in the subcoracoid space as nerve roots transverse beneath the pectoralis minor tendon
- Classification: neurogenic, venous, or arterial
(testing via imaging and EMG, treatment is conservative)
____, ____, ____, ____, ____, and ____ can cause thoracic outlet syndrome
Trauma, repetitive motions, anatomic variations, tumors / enlarged lymph nodes, injury to neck or back, and poor posture can cause thoracic outlet syndrome
____ is the most common type of thoracic outlet syndrome
Neurogenic thoracic outlet syndrome is the most common type of thoracic outlet syndrome
Describe neurogenic thoracic outlet syndrome
Neurogenic thoracic outlet syndrome
- Most often bilateral and with normal neurologic exam
- F > M
- Teens to 60s
- 95% of thoracic outlet syndrome cases
- Symptoms: upper limb parasthesias, trapezius pain, neck pain, shoulder/arm pain, supraclavicular pain, occipital headache, chest pain, parasthesias in fingers
Neurogenic thoracic outlet is most often ___ and with ___ neurologic exam
Neurogenic thoracic outlet is most often bilateral and with normal neurologic exam
Describe venous thoracic outlet syndrome
Venous thoracic outlet syndrome
- Most often unilateral affecting dominant upper extremity
- Subclavian vein compression commonly within costoclavicular space - bllod flow stagnation and effort thrombosis
- Paget-Schroetter disease (effort thrombosis): axillary or subclavian venous thrombosis following strenuous repeated activity with the arms
- M>F
- 15-45 years old, physically active
- 3-5% of cases
In venous thoracic outlet syndrome, presentation of the upper extremity involves ___, ___, ___, and ___
In venous thoracic outlet syndrome, presentation of the upper extremity involves swelling, cyanosis, heaviness, and pain
- Associated with unilateral Raynaud-like symptoms, pulmonary embolism
Venous thoracic outlet syndrome is associated with ____ and ____
Venous thoracic outlet syndrome is associated with Raynaud-like symptoms and pulmonary embolism
Describe arterial thoracic outlet syndrome
Arterial thoracic outlet syndrome
- Predominantly unilateral
- Subclavian artery compression within costoclavicular space may be caused by anomalous first rib
- May be seen in physically active patients - arterial entrapment occurs at level of pectoralis minor tendon and humeral head
- Arterial compression -> intimal damage, turbulent blood flow, vessel dilation
- Arterial thrombosis and distal embolization -> distal upper extremity ischemia
- Clinical features: primarily vascular, secondary neurologic abnormalities as sequelae
- M = F, young adults
- 1-2% (rarest)
Describe DVT presentation
DVT presentation
- Pain (typically throbbing)
- Leg swelling / edema
- Redness / erythema
- Increased warmth
- Pain comes on while walking or bearing weight
- Some patients are asymptomatic and DVT is incidentally found
DVT most commonly occurs in the ____
DVT most commonly occurs in the distal veins
DVT is usually treated with ____
DVT is usually treated with anticoagulation
Describe Baker’s (popliteal) cyst
Baker’s (popliteal) cyst
- Fluid-filled distention of a pre-existing bursa in the medial popliteal fossa: most commonly gastrocnemio-semimembranosus bursa
- Bursa communicates through an opening in the joint capsule posterior to the medial femoral condule
- Opening creates a valve-like mechanism in the presence of effusion that contributes to formation
Describe presentation and testing of Baker’s cyst
Baker’s cyst
- Often associated with othe intra-articular pathologies and inflammatory conditions, can be asymptomatic, can rupture w/o knee previous knee pain, usually in older individual, associated with mild to moderate leg edema ± bruising, difficult to palpate
- Best seen by MRI but may be seen on ultrasound or venous Doppler
Ruptured baker cyst can compress ____ and ____ and can present similar to a ____
Ruptured baker cyst can compress popliteal artery/vein with subsequent ischemia or thrombosis and the tibia or peroneal nerve and can present similar to a DVT
Popliteal fossa borders are the ____, ____, and ____
Popliteal fossa borders are the biceps femoris tendon superolaterally, semimembranosus muscle and semitendinosus tendon superomedially, and medial and lateral heads of the gastrocnemius muscle inferomedially and laterally
Describe popliteal artery entrapment
Popliteal artery entrapment
- Incidence of up to 3.5%
- Bilateral in < 50%
- Young and athletic with intermittent calf or foot claudication ± coldness, numbness, or parasthesias
- Pain at rest not common
- Anatomic cause: anatomic anomaly
- Functional cause: muscle hypertrophy with normal anatomy
- Physical exam often normal
Ankle-brachial index is ___ and is abnormal if ___
Ankle-brachial index is ratio of blood pressure at ankle to blood pressure at arm and is abnormal if ≤ 0.9
(used for popliteal artery entrapment)
Describe testing and treatment for popliteal artery entrapment
Popliteal artery entrapment
- Test: ankle-brachial index, ultrasound for Doppler, MRI/MRA, angiography
- Treatment: surgery if pervasive symptoms
Atherosclerosis is ____ and commonly affects ____, ____, ____, and ____
Atherosclerosis is plaque buildup inside artery and commonly affects CIA, SFA, popliteal artery, and tibial arteries
Describe peripheral artery disease
Peripheral artery disease
- Most commonly due to atherosclerosis
- Many patients asymptomatic but some with intermittent claudication
- Most patients have ischemic heart disease
- Few progress to critical limb ischemia
- Can present similarly to other painful conditions
- Can coexist with peripheral polyneuropathy
- Treatment is modifying risk factors and exercise
_____ is the physican exam finding most specific for peripheral artery disease and _____ index should always be done in cases of suspected peripheral artery disease
Lack of palpable pulse is the physican exam finding most specific for peripheral artery disease and ankle-brachial pressure index should always be done in cases of suspected peripheral artery disease
