Term
causes of bilateral leg swelling?
what is the most common cause of swelling? |
|
Definition
systemic disease e.g. HF with increased venous return
most common cause of swelling is oedema. |
|
|
Term
| causes of unilateral leg swelling? |
|
Definition
| local trauma, venous or lymphatic disease, DVT, cellulitis |
|
|
Term
| list some localised unilateral causes of limb swelling? |
|
Definition
trauma
bone malignancy
DVT
chronic venous insufficiency
lipodermatosclerosis
varicous veins
cellulitis
bakers cyst
stasis from obesity |
|
|
Term
| list some systemic causes of bilateral limb swelling |
|
Definition
CCF
malnutrion, low oncotic pressure
medication: calcium agonist, NSAIDs
hypothyroid - pre tibial myxedema
obstructive sleep apnoea - don't ask me how. |
|
|
Term
| in which condition might you see hemosiderin pigmented itchy scaly eczematous skin? |
|
Definition
| chronic venous insufficiency |
|
|
Term
|
Definition
| abnormal break in an epithelial surface |
|
|
Term
| what are the main causes of leg ulcers? |
|
Definition
70% due to venous disease
15% mixed arterial and venous disease
2% due to arterial disease alone.
pressure sores can also cause ulcers. |
|
|
Term
| list the classification of ulcers e.g venous, arterial neropathic etc |
|
Definition
Venous, arterial, neuropathic, lymphoedema, infective (TB),
traumatic (pressure ulcer)
pyoderma grangrenosum
drug induced ulcer, e.g from steroids |
|
|
Term
what questions should you ask in ulcer taking history?
what is the name given to self induced ulcers? |
|
Definition
pain, numbness, trauma and comorbidities (varicose veins PVD, DM, vasculitis)
are they on steroids?
has a biopsy been taken?
self cause ulcers are called dermatitis artefacta |
|
|
Term
| the area over the medial malleolus is known as Gaiter's area. this is a common spot for which type of ulcers? |
|
Definition
|
|
Term
| name the condition where there is inflammation of the SC fat due to venous insufficiency. |
|
Definition
| Lipodermatosclerosis. There is induration, pigmentation and inflammation of the skin. Minimal trauma to leg often leads to ulceration which takes many months to heal. |
|
|
Term
| how does temperature play a part in distinguishing between ischemic ulcers and those due to local factors? |
|
Definition
ischemic ulcers are cold
those due to local factors are warm. |
|
|
Term
| how long do you have an ulcer for for it to be chronic? |
|
Definition
|
|
Term
| what is TB colliquativa cutis? |
|
Definition
| when an infected lymph node ulcerates through the skin |
|
|
Term
| what tissue would be present if an ulcer is healing? |
|
Definition
| granulation tissue. Deep pink gel like matrix. |
|
|
Term
watery discharge favours TB
what does a bloody discharge favour? |
|
Definition
malignancy.
Associated lymphadenopathy suggests infection or malignancy |
|
|
Term
| why may a biopsy be necessary? |
|
Definition
| to assess for vasculitis or a malignancy in an established ulcer. |
|
|
Term
| what is the name of the SCC that presents in a chronic wound? |
|
Definition
|
|
Term
which is the best bandage to use in ulcer mx?
what should the ABPI be in order to be able to use a compression bandage? |
|
Definition
| Charing-Cross 4 layered bandage. ABPI must be > 0.8 |
|
|
Term
| what kind of therapy can be good to aid the healing in diabetic ulcers? |
|
Definition
| negative pressure wound therapy e.g VAC |
|
|
Term
| Surgery, larval therapy and hydrogels are used to debride sloughy necrotic tissue. In which type of ulcers should you avoid hydrogels and why? |
|
Definition
| in diabetic ulcers due to increase risk of wet gangrene. |
|
|
Term
| should you use prophylactic Abx in ulcers? |
|
Definition
| Routine use of Abx does not improve healing so Abx should only be used if there is an infection not colonization. |
|
|
Term
| gangrene is a sign of critical ischemia. differentiate between dry and wet gangrene. |
|
Definition
dry gangrene: necrosis without infection. There is a line that demarcates the living and dead tissue.
Rx: restore blood supply +/- amputation
Wet gangrene: tissue death and infection
rx: analgesia, broad spec IV Abx, surgical debridement +/- amputation |
|
|
Term
| which organism typically causes gas gangrene and muscle death in affected limbs? |
|
Definition
Clostridium. risk factors: DM, trauma and malignancy
rx: remove all dead tissue e.g. amputation. Give benzylpenicillin +/- clindamycin. Hyperbaric O2 can improve survival and decrease the number of debridements. |
|
|
Term
which organism is responsible for necrotising fasciitis?
What is Fourniere's gangrene? |
|
Definition
Group A B-hemolytic strep
Fourniere's gangrene is when necrotising fasciitis is localised to the scrotum and perineum.
Rx: radical debridement +/- amputation, IV Abx e.g. benpen and clindamycin |
|
|
Term
causes of unilateral limb swelling?
causes of bilateral?
what is the most common cause of swelling? |
|
Definition
unilateral: local causes e.g. DVT or cellulitis
bilateral: systemic causes e.g. HF
most common cause: oedema, xs fluid in interstitial space. |
|
|
Term
| localised causes of unilateral limb swelling. |
|
Definition
Trauma
DVT
chronic venous insufficiency, lipodermatosclerosis.
VV
Cellulitis
allergic reaction
bakers cyst
lympoedema due to malignancy
stasis |
|
|
Term
| systemic causes of bilateral limb swelling. |
|
Definition
CCF
AKI, nephrotic syndrome
drugs e.g. calcium channel blockers, NSAIDs
hypothyroid; pre tibial myxoedema |
|
|
Term
| in chronic venous insufficiency the skin can become itchy, eczematous and change colour due to deposition of which pigment? |
|
Definition
|
|
Term
| unilateral edema, pain and swelling In a leg implies? |
|
Definition
DVT
inflammation e.g cellulitis
bakers cyst.
insect bites |
|
|
Term
| in limb swelling with bone and muscle pain what are we thinking? |
|
Definition
tumours
necrotising fasciitis |
|
|
Term
| in limb swelling with impair mobility what dx are we thinking? |
|
Definition
| trauma, arthritis or a baker’s cyst. |
|
|
Term
| which infection affects dermic and SC tissue and has poorly demarcated borders? |
|
Definition
|
|
Term
which infection affects the dermis and upper SC tissues?
How is the border of this infection? |
|
Definition
Erypselas.
The border is sharply demarcated and can be very pain AKA St Antony's fire. |
|
|
Term
| Risk factors for cellulitis and eripsypelas? |
|
Definition
underlying disease, DM, cancer, immunodeficiency
previous cellulitis or erysipelas
venous insufficiency, elderly, alcoholic, athletes foot
IVDU, lymphedema, obesity, pregnancy
insect bites, inflammatory dermatoses |
|
|
Term
| Cellulitis in surgical wounds < 24 hours post op may be to due with which 2 organisms? Which organism would cause crepitus on examination? |
|
Definition
Group A B-hemolytic strep
C. perfringes. C per fringes would cause crepitations on examination.
crepitis is most commonly observed with anaerobic infections |
|
|
Term
| what areas are commonly affected with erysipelas? |
|
Definition
face or leg followed by arm or upper thigh.
with the face there has usually been a recent nasopharyngeal infection.
Malaise, chills and flu symptoms often precede skin lesion +/- vomiting |
|
|
Term
| rx for cellulitis and erisypelas? |
|
Definition
Flucoxicillin (penicillin) 500mg QDS
if allergic use a macrolide.
2nd line is clindamycin |
|
|
Term
| complications of cellulitis erysipelas? |
|
Definition
abscess
gangrene
chronic oedema
necrotising fasciitis
osteomyelitis
compartment syndrome
glomerulonephritis
septicemia
toxic shock |
|
|
Term
|
Definition
AKA gravitational or statis exczema.
skin changes due to increased venous pressure in the legs.
can be cause by obstruction by incompetent valves. the valves can be superficial or deep. it may also be due to thrombosis in deep veins. |
|
|
Term
| what is the pathophysiology of varicose eczema? |
|
Definition
| there is leakage of blood products into surrounding tissues. this causes an inflammatory reaction resulting in local skin changes. |
|
|
Term
| what skin changes are seen in varicose eczema? |
|
Definition
pigmentation from hemosiderin deposition
inflammatory changes and eczema
lipodermatosclerosis
atrophie blanche
Contact dermatitis may result from creams, ointments and dressing e.g. lanolin, rubber or Abx |
|
|
Term
| what is lipodermatosclerosis? |
|
Definition
inflammation of SC fat. it causes fibrosis and hard tight skin that may be red or brown.
seen in varicose eczema |
|
|
Term
|
Definition
| it is seen in varicose eczema. it is star shaped white atrophic areas of skin that are surrounded by reddened areas. there is ulceration of the skin. |
|
|
Term
| people with VV undergo eczema skin chafes. approximately how many %. what ages does it affect the most? |
|
Definition
~10% of pts with VV undergo skin changes.
it affects 20% of those > 70 years. |
|
|
Term
| how would you ascertain if venous HTN is present? |
|
Definition
VV or VV surgery. please note some venous HTN present without VV
past hx of DVT or leg ulcers. |
|
|
Term
| examination and what to look for in VV and venous eczema |
|
Definition
poorly define scaling and redness around ankle
characteristic pigmentary changes and hemosiderin deposition
distribution is characteristic: starts just over or just above malleoli
there is erythema and dryness of the skin. |
|
|
Term
| in which area would lipodermatosclerosis be typically found? |
|
Definition
in the inner aspect of calf.
SC tissues can become hard and depressed |
|
|
Term
| where would you find atrophy blanche? |
|
Definition
| in an area where an ulcer has usually healed. they are star shaped white-ivory scars that are surrounded by pigmentation. |
|
|
Term
| investigations of Venous insufficiency and VV |
|
Definition
consider ABPI
Do Duplex USS to confirm varicose veins. |
|
|
Term
| mx of venous insufficiency |
|
Definition
avoid skin injury, elevate legs when sat, keep active
regular emollient and steroids for flare ups
if there is no arterial insufficiency then use below knee compression socks.
infection may need Abx |
|
|
Term
classes of compression socks
in what range of ABPI would you not needs stockings? |
|
Definition
3 classes.
1 is the lightest
3 is the strongest
if ANPI is < 0.3 or > 1.3 socks are not needed |
|
|
Term
| what homeopathic medication might help chronic venous insufficiency? |
|
Definition
| PO horse chestnut seed extract may be helpful for symptoms of chronic venous insufficiency. |
|
|
Term
| complications of venous insufficiency? |
|
Definition
cellulitis
contact dermatitis
ulceration |
|
|
Term
|
Definition
age
immobility
past DVT
cancer or rx within past 6 months
obesity
thrombophilia
pregnancy
synthetic estrogen
trauma/ surgery |
|
|
Term
true or false
65% below knee DVT are asymptomatic and rarely embolize to the lung |
|
Definition
|
|
Term
|
Definition
calf warmth
tenderness, swelling
mild fever
pitting oedema |
|
|
Term
|
Definition
cellulitis
ruptured baker's cyst
both may co exist with DVT |
|
|
Term
| what tests do we do in DVT |
|
Definition
D dimer
USS
CTPA - gold standard. |
|
|
Term
| what is the sensitivity and specificity status of D dimer testing? |
|
Definition
sensitive but not specific
also raised in
pregnancy
post op
malignancy
infection |
|
|
Term
| what does a negative d dimer and low pre test score suggest? |
|
Definition
DVT unlikely.
if D dimer is raised or pt has an intermediate pre test score then we should do an USS. |
|
|
Term
| what other tests could you do especially if you cannot find a cause for the DVT and they are reoccurring? |
|
Definition
You can do a thrombophilia screen, look for malignancy, if the women is >40 then do mammography.
Ix; urine, FBC, LFT, Ca2+, CXR +/- CT abdo/pelvis +mammorgraphy in females if >40 years |
|
|
Term
rx of DVT.
what would you use in renal failure or pts with increased bleeding risk? |
|
Definition
LMWH SC 1.5mg/kg/24h
unfractionated heparin used in renal failure or if there is increased bleeding risk. |
|
|
Term
| how long should cancer pts receive LMWH for? |
|
Definition
6 months and then review.
In others start warfarin simultaneously with LMWH. (warfarin is prothrombotic for the first 48h). stop heparin when INR 2-3 |
|
|
Term
| what is the length of rx for DVT? |
|
Definition
6m for unprovoked DVT
3m for provoked.g. underlying cause or post op
lifelong rx if recurrent or thrombophilia. |
|
|
Term
| if there is active bleeding to if anticoagulants fail what can be installed to recent PE? |
|
Definition
IVC filter.
Graduated compression stockings help prevent long term complications of DVT such as pain, swelling and skin changes. |
|
|
Term
|
Definition
| Long torturous and dilated veins of the superficial venous system. |
|
|
Term
| explain the pathophysiology of VV |
|
Definition
blood from superficial veins pass to deep veins via perforator veins that perforate the deep faschia. this also happens at the sapheno-femoral and sapheno-popliteal junctions.
valves prevent blood from passing the other way i.e from deep to superficial veins but if they become incompetent then there is venous HTN causing dilation of the superficial veins. |
|
|
Term
| what are risk factors for VV? |
|
Definition
prolonged standing
obesity
pregnancy
FHx
the pill |
|
|
Term
|
Definition
idiopathic, congenital valve absence
2nd causes
Obstruction: DVT, fetus, ovarian tumour
valve destruction: DVT,
AV malformation: increases pressure
Constipation
overactive muscle pumps e.g. cyclists |
|
|
Term
|
Definition
pain
cramp
heaviness
tingling
restless legs
also ' my legs are ugly' |
|
|
Term
| signs of VV (same signs as venous insufficiency) |
|
Definition
oedema
eczema
ulcers
pigmentation
atrophie blanche
lipodermatosclerosis |
|
|
Term
| how would you perform an examination for VV? |
|
Definition
start with pt standing:
inspect for ulcers around medial malleolus and hemosiderin deposition
inspect anterior thigh to medial calf: long saphenous vein
back of calf: short saphenous venous
palpate veins:
tenderness = phlebitis
hardness = thrombosis
if there are ulcers then palpate pulses to rule out arterial disease.
test for cough impulse at saphenofemoral jx (SFJ). positive test indicates incompetence.
percussion tap test: here you tap the vein distally and feel for the transmitted impulse at the SFJ. If valves were working then they would interrupt transmission of the impulse.
listen over varicosities for a bruit. it indicates AV malformation
For completion examine the abdomen, the pelvis in females and external genitalia in males for masses. |
|
|
Term
| which test allows you to listen for incompetent flow across valves? |
|
Definition
Doppler USS
you can listen at the SFJ
you can listen behind the knee for the short saphenous vein.
procedure: calf is squeezed then released. on release flow lasting > 1/2 - 1 second suggest significant reflux. if incompetence is not ID and rx then varicosities will return. |
|
|
Term
| what are the treatment options for VV? |
|
Definition
conservative: education: avoid prolonged standing, raise legs when possible, support stockings, lose weight, regular walks because calf muscle action aids venous return
Endovascular Rx – less pain and earlier return to activity than surgery
Radiofrequency ablation: catheter inserted into the vein and heated to 120 Celsius destroying the endothelium and closing the vein.
Endovenous laser ablation: similar to above but with lasers
Injection sclerotherapy: can use liquid or foam.
surgical rx
Saphenofemoral ligation (Trendelenburg procedure)
Multiple avulsions
Stripping from groin to upper calf, stripping to ankle is not needed and may damage the saphenous nerve.
Post op: bandage legs tightly and elevate for 24hours |
|
|
Term
| what is critical limb ischemia? |
|
Definition
ischemia at rest; pain, ulcers or gangrene in one or both legs.
This is attributable to objectively proven arterial occlusive disease.
Critical limb ischemia implies chronicity and should be distinguished from acute limb ischemia. |
|
|
Term
| causes of critical limb ischemia |
|
Definition
thormbosis
embolism
trauma
raynauds
compartment syndrome |
|
|
Term
what investigations should you do in critical limb ischemia?
what ix to do if diagnoses is in doubt? |
|
Definition
Handheld doppler: can should residual artery flow
FBC: check for anemia, it aggravates ischemia
ESR: inflammatory disease e.g. GCA
glucose: DM, lipids, thrombophilia screen
ECG, echo, femoral, popliteal and aortic US.
if diagnosis in doubt do urgent arteriography. |
|
|
Term
| how to manage critical limb ischemia |
|
Definition
immediate heparin: may double limb salvage rate and provide analgesia
if compartment syndrome do fasciotomy
if thrombosis: intra arterial thrombolysis, angioplasty or bypass. if it is thrombosis of an arterial graft then thrombolysis is 1st step
if embolism: embelectomy using Fogarty balloon catheter or local intra arterial thrombolysis. if this fails do angiogram and bypass or intra operative thrombolysis. |
|
|
Term
what aftercare is needed after successful embelectomy?
what do some surgeons do with this aftercare and why? |
|
Definition
anticoagulation with heparin to prevent reoccurrence.
Some surgeons post phone heparin for 6h post op to reduce the risk of hematoma |
|
|
Term
| what rx would you give to pt with emboli/thormbosis presenting with limb ischemia? |
|
Definition
immediate systemic anticoagulation with unfractionated heparin.
Followed by long-term warfarin in pts with embolism. |
|
|
Term
| how is intra arterial thrombolysis carried out? |
|
Definition
first do an arteriogram then advance catheter into the thrombus.
Streptokinase, urokinase of tPA is mixed with heparin.
continue thrombolysis for 48h or until clot has lysed. |
|
|
Term
how long does fibrinolysis usually take? what implication does this have for acute limb ischemia?
who is local thrombolytic tx (fibrinolysis) reserved for? |
|
Definition
6-72 hours.
it it too long for those with acute limb ischemia. they are not suitable candidates for fibrinolysis and require emergency embelectomy.
local thrombolytic tx reserved for those with non life threatening limb ischemia |
|
|
Term
| what are the complications of thrombosis? |
|
Definition
haemorrhage
stroke
distal embolisation |
|
|
Term
CI to thrombolysis
what to do if a limb is irreversibly ischemic? |
|
Definition
critical ischemia + neuro deficit + irreversible ischemic changes
in irreversible ischemia amputation is needed. |
|
|
Term
| other mx for chronic limb ischemia |
|
Definition
conservative: stop smoking, good diabetes control, exercise
medical: rx HTN and high lipids. rx anemia, polycythemia or CVS disease
Clopidogrel or low dose aspirin. |
|
|
Term
| complication of critical limb ischemia |
|
Definition
reperfusion injury
compartment syndrome due to increased capillary permeability
neutrophils migrating into area causing inflammation
leakage from damaged cells may cause acidosis and hyperkalemia; can cause myoglobinuria or cardiac arrhythmias
acute complete ischemia can lead to peripheral nerve injury. |
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|
