Swollen calf Flashcards
DDx for an acutely swollen calf
DVT
Cellulitis
Ruptured bakers cyst
Muscular strain (e.g. torn gastrocnemius)
Septic arthritis
Compartment syndrome
Local reaction (e.g. allergy to insect bite)
Cause of bilateral leg swelling
Most likely systemic vessel problem e.g. its peripheral oedema Right heart failure Lymphoedema Venous insufficiency Pregnancy Vasodilators (e.g. calcium channel blockers = amlodipine) Hypoalbuminaemia (can be as a result of kidney failure (nephrotic syndrome), malabsorption, sepsis FLUID OVERLOAD!
What is Virchow’s triad?
Endothelium integrity
Flow of blood
Coaguability
RF of coagulation
Recent surgery (reduced flow, increased stasis)
Dehydration, DKA
Malignancy = high risk of clot formation
Long haul flight
Abdominal mass pressing on X can cause limb swelling
Iliac vein
Whats the cut off for likely DVT when using the Well’s score?
> /=2
Ix for DVT
Doppler ultrasound of proximal leg veins (can also spot a ruptured Baker’s cyst)
Serum D dimer levels (D-dimer = fibrin degradation product)
Immediate treatment of DVT
LMWH (treatment dose)
OR
fondaparinux (Xa inhibitor)
Long term DVT management
Anticoagulation (warfarin or rivoroxaban)
Stockings (potentially for years on the affected limb)
Lifestyle advice and medication discussion (HRT stopped, weight loss)
Broken tibia , excruciating leg, cannot feel his toes, red, tender, swollen calf.
What is the immediate management?
This is compartment syndrome
Happens because muscles are surrounded by tight inelastic fascia
Occlusion -> swelling -> more occlusion
Needs urgent decompression = fasciotomies
Send them to theatre straight away
Irreversible atrophy due to compartment syndrome is known as?
Volkmann’s contracture
Superficial, red swelling in ankle most likely caused by..
An inflammatory response to an insect bite
Cellulitis
Management = mark the size of the swelling
FBC for WCC (systemic infection)
Antibiotics to cover staph and strep
Consider topical steroids if looking like an insect bite
Insect bite swelling Mx
Topical steroids to dampen immune response
Antihistamines
Treatment of a ruptured Baker’s cyst
Elevation of the affected limb
Aspiration of fluid
Injection of corticosteroids into the knee
All to reduce inflammation and pain
Who is at increased risk of Baker’s cysts?
Osteoarthritics
Why can ruptured Baker’s cysts present with swelling in the leg?
The fluid tracks down
Clinically indistinguishable from a DVT, need a doppler ultrasound to really rule it out
DVT prevention methods
Compression stockings (if pregnant, cancer, HF, other RF) Can consider LMWH injection (consult local haematology team)
Mutations that make you more likely to clot
FV Leiden
Protein S/C deficiency
Conditions that increase risk of clotting
Malignany DIC COCP/HRT HIT! Polycythaemia DKA Antiphopsholipid syndrome
What should you start warfarin with?
LMWH because of a paradoxical increase in likelihood to clot initially
Contraindications to warfarin treatment
Pregnancy
Severe hypertension (risk of haemorrhagic stroke)
Peptic ulcer disease (or any active bleeding really)
Warfarin side effects
Haemorrhage
N+V
Purple toes and skin necrosis
Hepatic dysfunction and jaundice
What should pt on warfarin avoid?
Alcohol
Cranberry juice
St John’s wort
Patient on max anticoagulation still having clots from DVT, what can you do?
Insert inferior vena cava filter
Target INR for patients with proven DVT
2-3
Cellulitis antibiotic = X
What does it cover?
Flucloxacillin
Staph aureus and strep pyogenes
Red, swollen calf Considerable, disproportionate pain High fever and appear very unwell The redness has rapidly increased Blistering dark purple patches What do you need to consider as a priority?
Necrotising fasciitis
Blistering skin = BAD NEWS
