Swollen Calf Flashcards
What are the main causes of an acutely swollen calf?
- DVT
- Cellulitis
- Ruptured Baker’s cyst
- Muscular strain (e.g. torn gastrocnemius)
- Septic arthritis (knee, ankle)
- Allergic response e.g. to insect bite
- Compartment syndrome
- Swollen leg post leg surgery normal (must exclude DVT)
- can coexist
What are causes of bilateral swollen legs?
- Right heart failure (in isolation or together with left heart failure)
- Lymphoedema
- Venous insufficiency
- Pregnancy
- Vasodilators (CCB’s)
- Hypoalbuminaemia: from renal failure (nephrotic syndrome), liver failure, malabsorption/malnutrition, sepsis
- Pelvic tumour (e.g. ovarian) compressing IVC
- Fluid overload (iatrogenic)
What questions must you ask in the history of a swollen leg?
- RF for venous thrombosis
- Felt breathless, had any chest pain or coughed up any blood?
- Has she had any cuts, insect bites or other wounds to her right left?
- Is swelling getting bigger
- Has she had any abdominal pain? Has she noticed any blood in her feaces? Has she had any unusual vaginal bleeding? Has she noticed any weight loss, fever, or malaise?
- Has she recently had radiotherapy, or surgery to right leg of abdomen?
- Does moving the joints in her leg elicit pain?
What is Virchow’s triad?
- hypercoagulable blood
- stasis
- vessel injury
What can cause hypercoagulable blood?
- trauma
- major surgery in later 3 months
- pregnancy and post partum state
- IBD
- active cancer
- obesity
- combined oral contraceptive pill
- HRT
- FHx or PMHx of DVTs
What can cause stasis?
bed rest (>3 days) or long-haul travel
What can cause vessel injury?
- trauma
2. surgery
Why do you ask about breathlessness, chest pain, cough blood?
PE
Why do you ask about inject bites, cuts and wounds?
infective disease such as cellulitis and septic arthritis
Why do you ask if swelling is getting bigger?
cellulitis can spread rapidly along affected limb, others remained confined in ST
Why do you ask about abdominal pain etc.?
considering pelvic malignancy as cause of limb swelling: ask about symptoms suggestive of colon, ovarian or uterine malignancies
Why do you ask about radiotherapy and surgery?
damage lymphatic drainage from her affected limb, causing accumulation of lymph (lymphoedema)
What sort of pain would moving the joint elicit in septic arthritis?
excruciating
On examination of the swollen calf what are you looking for?
- cuts, bites, wounds, superficial infection
- location of swelling
- extent of swelling
- lymphadenopathy
- abdominal masses
- neurovascular status of limb
- pain on general passive movement
- febrile
Where must you always check for entry of infection?
between toes for fungal infection as portal for entry
Where would the location of swelling be in septic arthritis?
over joint (ankle, knee)
Where would the location of swelling be for compartment syndrome?
inflammation which is confined to calf or thigh muscle compartments but spares the joints
What is Baker’s cyst?
ruptured synovial sac in the knee
Where would the location of swelling be for a Baker’s cyst?
emerge from popliteal fossa and track down into the calf
How do you measure the extent of swelling?
- measure using tape measure to compare circumference of both limbs at same point (e.g. 10cm below the tibial tuberosity)
- mark the area of swelling and/or erythema with a pen so can monitor progression
When do you check for lymphadenopathy?
swollen lymph nodes in popliteal fossa and in groin
Why are you checking for lymphadenopathy?
suggestive of infection in the limb
What would an abdominal mass in the RLQ with a swollen calf suggest?
tumour compressing right iliac vein
How do you determine neurovascular status of limb?
- sensation
- motor function
- pulses
- distal to swelling
Why are you checking the neurovascular status of limb?
affected by compartment syndrome and compromise of neurovascular status surgical emergency
What would pain on general passive movement be like in septic arthritis?
pain in affected joint
What would pain on general passive movement be like in compartment syndrome?
pain in calf
Why do you need to move the joint slowly with passive movement?
avoid dislodging any DVTs into circulation
What would a low grade pyrexia with a swollen calf suggest?
DVT
What would a significantly raised temp with a swollen calf suggest?
infective cause
What score do you use for the probability of patient having DVT?
Well’s score
Does the Well’s score system ever change?
different for DVT and PE
What are the investigation and acute management of suspected DVT?
- Doppler US of the proximal leg veins
- Serum D-dimer levels
- FBC and clotting studies
- Anticoagulation
Why do you do a doppler US of proximal leg veins?
- most sensitive, rapid and non-invasive way of visualizing a DVT in lower limb
- US enable a ruptured Baker’s cyst to be diagnosed
When are serum D-dimer levels elevated?
- DVTs
2. PEs
What other different conditions can cause a elevated D-dimer?
- Cellulitis
- Acute coronary syndromes
- AF
- Pneurmonia
- Vasculitis
- Sickle cell crises
- Superficial phlebitis
- malignancies
- disseminated intra-vascular coagulation
What would a low Well’s score and normal D-dimer help with?
rule out DVT without need for acute US
What would a high Well’s score and elevated D-dimer help with?
indication for performing repeat US after 6-8days after the first one
What would a high WCC suggest with swollen calf?
cellulitis
What would a high RBCC suggest with swollen calf?
polycythaemia rare cause of DVT
Why do you do clotting studies?
can reveal deranged coagulation
When are people supposed to get their US?
gold standard within 4hr of request
When is anticoagulation given acutely?
if low risk for bleeding given LMWH or novel oral anticoagulant before scan next day
What does the management of DVT involve?
- anticoagulation
- compression stockings
- lifestyle advice
Why do you give anticoagulation in the management of DVT?
prevent clot extension, PE and reccurence
Which anticoagulation is used?
LMWH or fondaparinux
When do you give unfractioned heparin?
significantly impaired renal function, or at risk of bleeding (post op patients)
What are the ongoing anticoagulations offered?
- rivaroxaban
- warfarin
- LMWH if underlying malignancy
What needs to be monitored with patients taking warfarin?
INR
How long should the parenteral anticoagulant be continued for?
5 days or until INR in range for more than 24hr
What sort of compression stockings are offered?
elow knee graduated compression stocking (ankle pressure >23mmHg) to be worn 1 week after diagnosis or after leg swelling reducing
How long should the compression stocking be worn?
2 years on affected limb and replace 2-3 a year
How long should the compression stocking be worn?
2 years on affected limb and replace 2-3 a year
What lifestyle advice should be offered for management of DVT?
- cessations of combined oral contraceptive pill, HRT
2. weight loss
