Swollen Calf

Question 1

What are the main causes of an acutely swollen calf?

Answer 1

1. DVT
2. Cellulitis
3. Ruptured Bakers cyst
4. Muscular strain (e.g. gastrocnemius injury)

Note different pathologies can coexist - e.g. ruptured Bakers cyst and DVT

Question 2

If BOTH calves are swollen, what are the differential diagnoses?

Remember, BOTH legs swollen indicates a systemic/central vessel problem

Answer 2

1. Right heart failure (in isolation or with left heart failure)
2. Lymphoedema
3. Venous insufficiency
4. Pregnancy
5. Vasodilators (Eg CCBs - Amlodipine)
6. Hypoalbuminaemia (from renal failure, liver failure, malabsorption, etc)
7. Pelvic tumour compressing IVC

Question 3

What specific questions would you ask if someone complains of right calf swollen. DVT highest priority

Answer 3

Remember Virchows triad

1. Hypercoagulable blood - trauma/major surgery within 3 months/pregnancy/postpartum state/IBD/Cancer/Oral contraceptive/HRT/PMH of DVTs
2. Stasis - bedrest in the last 3 days / long haul travel
3. Vessel injury - trauma/surgery

Question 4

If DVT is high on the differential list, what other symptoms would be useful to look out for?

Answer 4

Breathless, chest pain, coughing up blood (all symptoms of Pulmonary embolism)

Question 5

What sort of history may indicate cellulitis/septic arthritis

Answer 5

Cuts / insect bites / other wounds to leg

Question 6

Which condition may spread rapidly along affected swollen limb?

Answer 6

Cellulitis

Question 7

What sort of symptoms may indicate pelvic/uterine/ovarian malignancies?

Answer 7

Abdominal pain/blood in faeces/unusual vaginal bleeding/weight loss, fever, malaise

Question 8

What may increase the risk of lymphedema?

Answer 8

Radiotherapy/surgery - affects lymphatic drainage

Question 9

What is a giveaway that there is septic arthritis present?

Answer 9

EXCRUCIATING pain when moving the joint

Question 10

Oestrogen and progesterone based therapies increase risk of DVT. What else might

Answer 10

Long haul travel

Obesity

Question 11

Septic arthritis produces swelling typically over?

Answer 11

Over a joint (e.g. knee/ankle)

Question 12

Compartment syndrome typically produces inflammation confined to?

Answer 12

The calf/thigh muscle compartments - doesn’t cause inflammation of joints

Question 13

Bakers cyst would emerge where and track down where?

Answer 13

Bakers cyst = ruptured synovial sac in knee - emerges at popliteal fossa and trans down into calf

Question 14

Swollen lymph nodes in the popliteal fossa/groin indicates?

Answer 14

Lymphadenopathy - infection in the limb

Question 15

How could an abdominal mass in the lower right quadrant cause a swollen right leg?

Answer 15

Tumour compressing right iliac vein

Question 16

Decline in neurovascular state of the limb (distal to the swelling) may indicate?

Answer 16

Compartment syndrome - this is a surgical emergency.

Question 17

Low grade pyrexia may occur with DVT. Significantly raised temperature indicates?

Answer 17

Infection

Question 18

What scoring system is used for DVT?

Answer 18

Wells. A score of 2 or more indicates DVT likely

Question 19

Explain how D-dimer is used for excluding DVT

Answer 19

Used in conjunction with Wells score.

Wells score 2 or more = +1 ultrasound
D-dimer positive = +1 ultrasound

So if Wells score of 3 and positive D dimer, 2 ultrasounds required. 2nd ultrasound after first week if first ultrasound negative.

D-dimer is used to exclude DVT (if low D-dimer with low Wells Score)

Question 20

How is a DVT positively diagnosed?

Answer 20

Via an ultrasound (quickest and most sensitive).

Ultrasounds will also diagnose ruptured Bakers cysts

Question 21

What investigation can be done to rule out cellulitis or DVT (caused by polycythaemia)

Answer 21

Full blood count

Cellulitis = high WBC
Polycythaemia (causing DVT) = high RBC

Question 22

If ultrasound scan isn’t available on the same day, what treatment is given whilst awaiting an ultrasound the next day?

Answer 22

Low molecular weight heparin / oral anticoagulant

Question 23

How do you manage someone with DVT

Answer 23

1. Anticoagulation - acutely give LMWH / fondaparinux. If renal failure/high bleeding risk, give unfractionated heparin. Also give ongoing anticoagulants e.g. rivaroxaban or warfarin
2. Compression stockings - wear 1 week after diagnosis or after leg swelling has reduced. Wear for 2 years on affected limb
3. Lifestyle advice - consider HRT cessation

Question 24

Tense, shiny swollen limb painful to passive movement (& neurovascular compromise) suggests?

Answer 24

Compartment syndrome

Question 25

What is Volkmanns contracture?

Answer 25

When there is irreversible atrophy of the limb - due to high pressure in affected limb. Often as a result of compartment syndrome

Question 26

Compartment syndrome is a surgical emergency. How is it treated

Answer 26

Fasciotomy