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Semester 2 (3rd year) > Case 21: Limb Problems > Flashcards

Case 21: Limb Problems Flashcards

1
Q

what is an aneurysm

A

a dilation of an artery which is bound by all 3 walls of the vessel

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2
Q

what is a pseudoaneurysm

A

bleed from an artery which pools in an enclosed space next to the vessel

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3
Q

what is a dissection

A

the intima tears and blood enters, separating it from the media and creates a false lumen which can become aneurysmal and/or lead to reduction of distal blood flow

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4
Q

most common artery affected by aneurysm

A

AA

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5
Q

most common artery of the leg to be affected

A

popliteal

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6
Q

typical presentation of popliteal aneurysm

A

easy palpable popliteal
may have co-morbid abdominal aneurysm

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7
Q

complications of popliteal aneurysm

A

more likely to cause thrombosis rather than rupture- leads to acute limb ischaemia

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8
Q

management of popliteal aneurysm

A

for acute ischaemia- femoropopliteal bypass

is discovered before thrombosis- graft

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9
Q

what is an ulcer

A

a discontinuity of skin with complete break in the epidermis and possibly dermis and subcutaneous tissue

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10
Q

what is an erosion

A

a partial break in epidermis, appears bright red and weepy

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11
Q

causes of ulcers

A

trauma and/or internal pathology

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12
Q

types of ulcers

A

arterial
venous
vasculitis
neuropathic

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13
Q

what is the most common cause of neuropathic ulcers

A

diabetic foot

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14
Q

how to investigate causes of ulcers

A

ABPI for arterial disease
urine glucose for diabetes
test skin sensation and vibration is suspected neuropathic ulcer
doppler US for venous insufficiency
FBC, Us and Es and ESR may show signs of vasculitis, infection or arterial disease

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15
Q

management of ulcers

A

treat underlying cause- PVD, diabetes, vasculitis

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16
Q

are venous or arterial ulcers more common

A

venous
venous= 2/3
arterial= 1/3

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17
Q

pathophysiology of venous ulcers

A

venous insufficiency can cause fluid to leak from veins and capillaries leading to oedema and deposition of plasma proteins, including fibrinogen and inflammatory mediators

this leads to hypoxia, damage to local tissues and eventually ulceration

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18
Q

commonest cause of venous ulcers

A

incompetence of perforator veins

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19
Q

what does a venous ulcer look like

A

rough edge
redness

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20
Q

typical location of venous ulcer

A

medial leg along great saphenous vein

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21
Q

what may you see on surrounding skin of venous ulcer

A

purple/blue skin (blood) and/or brown (hemosiderin)

varicose veins

lipodermatosclerosis (inflammation of the subcutenaous fat causing pain and constriction of the soft tissue)

venous eczema (crust and weepy)

hot

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22
Q

management of venous ulcer

A

if slough is affecting healing can use desloughing dressing (iodine dressing)

usually use non-adherent dressing

surround with compression bandaging to squeeze fluid out over days, then compression stockings long term

elevation helps fluid drainage

antibiotics if signs of infection

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23
Q

management for venous ulcer with superficial vein incompetence

A

surgery (junction disconnection, stripping and avulsion) or endogenous ablation

this is not suitable post-DVT

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24
Q

how to manage venous eczema

A

betnovate (betamethasone)

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25
pathophysiology of arterial ulcers
caused by chronic peripheral vascular disease
26
risk factors for arterial ulcers
diabetes smoking
27
what do arterial ulcers look like
punched out appearance Clear edge
28
common places for arterial ulcers
distal pressure points- toes, pads, heels, maelloli
29
what may be surrounding skin of arterial ulcers be like
pale painful cool shiny hairless weak/absent pulse signs of infection
30
appearance of vasculitis ulcers
vessel destruction initially leads to purpura then necrosis (black/green/yellow areas) ulcers with a blue/purple edge then appear after a few days
31
what bacteria causes gangrene
Clostridium perfringens (releases alpha toxin)
32
how do you typically get gangrene
the bacteria inhabit the soil or normal gut flora enters in major trauma/GI surgery rarely is non-traumatic due to colorectal carcinoma or immunosupression
33
gangrene signs and symptoms
pain (may be sudden onset and out of proportion to symptoms) skin crepitus crackly on palpation skin becomes dark purple, swollen and bullae form septic shock
34
gangrene management
surgical debridement Iv antibiotics
35
what causes PVD
atherosclerosis of peripheral arteries
36
what limbs are most commonly affected by PVD
legs most commonly but can also affect arms
37
when does acute limb ischaemia progress to necrosis
within 6 hrs if untreated
38
commonest site affected by chronic PVD
the upper 2/3 of calf due to superficial femoral artery
39
2nd commonest site affected by chronic PVD
buttock and hip due to aortic and iliac artery
40
other sites affected by chronic PVD
thigh (iliac or common femoral artery) lower 1/3rd of calf (popliteal artery) foot (tibial or perineal artery)
41
what is claudication
predictable, reproducible pain on exertion causes by ischaemia of the muscle which is relieved by rest
42
predictable, reproducible pain on exertion causes by ischaemia of the muscle which is relieved by rest
30%
43
Qs to ask to assess claudication severity
how many yards can walk before having to stop due to pain, on flat at normal pace on their best day
44
definition of critical limb ischaemia
rest pain, unrelieved by medication for 2 or more weeks and/or evidence of tissue loss (ulcer/gangrene)
45
other features of critical limb ischaemia
pain may be absent due to neuropathy pain in feet and toes pain worse at night due to reduced gravitational pull swollen leg (may also be red from metabolite-triggered capillary dilation)
46
fontaine classification
is for chronic limb ischaemia 1= asymptomatic 2= intermittent claudication (2a if stops over 200m, 2b if less than 200m) 3= rest/nocturnal pain 4= necrosis/gangrene
47
acute limb ischaemia 6 Ps
pain at rest pulseless pale paraesthesia perishingly cold paralysis (late feature suggesting irreversible damage)
48
ABPI results
<0.9 is claudication <0.6 is rest pain <0.3 is gangrene
49
management of PVD
active- rehabilitation programmes CVD prevention clopidogrel= 1st line antiplatelet naftidrofuryl (vasodilator) can increase walking distance
50
management of acute limb ischaemia
heparin IV then embolectomy with Fogarty catheter thrombolysis with alteplase if not surgically fit
51
when would you consider amputation
ulceration and gangrene
52
what are varicose veins
tortuous dilated superficial veins usually in the legs
53
what is the usually cause of varicose veins
incompetent valves
54
vein affected when there are varicose veins along medial leg
sapheno-femoral function of the long saphenous vein
55
vein affected when there are varicose veins along lateral calf
sapheno-popliteal junction of the short saphenous vein
56
vein affected when there are varicose veins along medial calf
perforator veins
57
RFs for varicose veins
family history prolonged standing abdominal or pelvic masses compressing IVC or iliac veins (pregnancy, obesity)
58
investigation for varicose veins
doppler US
59
conservative management of varicose veins
compression therapy (stockings or graded compression bandaging) weight loss avoid prolonged standing simple analgesia if pain
60
surgical management of varicose veins
indicated if pain or ulceration SFJ ligation and vein stripping, stab avulsions, radiofrequency or laser ablation, injection of sclerosing foam
61
what medication must you stop before varicose vein surgery
must stop oral contraceptive pill 4-6 weeks pre-op due to DVT risk
62
modifiable risk factors for atherosclerosis
T2D obesity hypertension hypercholesterolaemia physical inactivity smoking
63
non-modifiable risk factors for atherosclerosis
T1D family history age sex
64
renal effects of atherosclerosis
hypertensive nephropathy hypertension resistant to medical treatment
65
cerebrovascular effects of atherosclerosis
TIA stroke amaurosis fugax drop attacks
66
peripheral vascular effects of atherosclerosis
intermittent claudication gangrene arterial foot ulcer ischaemia rest pain
67
coronary artery of atherosclerosis
angina ACS
68
mesenteric artery effects of atherosclerosis
post-prandial abdominal pain weight loss hypertension resistant to medical management
69
what is amaurosis fugax
transient unilateral loss of vision often described as 'a curtain falling' over their vision due to emboli passing into the ophthalmic artery, which is usually from a stenosis in the ipsilateral carotid artery
70
what are drop attacks
sudden episodes of dizziness or syncope
71
what is sunset foot
do buergers test affected leg is raised and held up for a while turns white and cold- may indicate chronic arterial stenosis of the lower extremity putting the leg down would resume blood flow to the foot under the effect of gravity, therefore the leg would regain its red discoloration this is called sunset foot sign
72
features of neuropathic ulcers
deep in depth pink wound bed small in size thickened/raised edge
73
features of arterial ulcers
sunset foot small sized punched out distal location black tissue
74
features of venous ulcers
thickened skin pink wound bed irregular edge shallow wound gaiter varicose veins
75
potential changes to the appearance of the limbs in chronic venous insufficiency
erythema ulceration oedema rash brown skin (due to haemosiderin deposition) thickened skin
76
potential symptoms of chronic venous insufficiency
night cramps itching aching restless legs pain heaviness
77
pathophysiology of varicose veins
venous insufficiency can be due to failing of the valves in the veins of the legs this means the veins aren't able to stop blood falling down the leg this means blood pools at the bottom of the legs, and the veins dilate to accommodate more common in standing occupations and pregnancy
78
pain in leg when walking differentials
musculoskeletal= knee oestoarthritis neurological= spinal canal stenosis peripheral arterial= intermittent claudication venous= chronic venous insufficiency
79
RFs for intermittent claudication
smoking hypertension male family history of CVD older age
80
red flag symptoms for the leg pain
rest pain- ischaemic rest pain warrants urgent referral to vascular night pain tissue loss sudden onset symptoms associated with sensorimotor deficit- indicative of acute limb ischaemia and is a medical emergency leg swelling- suggests DVT and needs duplex US to rule out
81
typical findings of intermittent claudication in right leg
right foot paler and cooler than the left with a delayed capillary refill on left femoral, popliteal, posterior tibial and dorsalis pedis pulses were palpable, but on the right only femoral no evidence of tissue loss
82
what actually causes the pain in intermittent claudication
the muscles have increased O2 demands during exercise which cannot be delivered due to the muscles compromised blood supply muscles most commonly affected are in calf due to femoral-popliteal vessels being affected
83
which exercise most commonly brings on intermittent claudication pain
walking (especially uphill)
84
what is atherosclerosis
hardening and narrowing of the arteries due to plaque (most commonly lipid)
85
symptoms of atherosclerosis in the coronary arteries
vomting anxiety angina coughing syncope/pre-syncope (can lead to MI)
86
symptoms of atherosclerosis in the carotid arteries
weakness headaches facial numbness paralysis (can lead to stroke)
87
symptoms of atherosclerosis in the kidneys
reduced appetite hand/feet swelling increased BP
88
how can atherosclerosis cause a thrombus
the plaque ruptures causes coagulation to stop the contents spilling out into he blood this creates a thrombus (this can go on to impede blood flow)
89
there is increase in which type of cholesterol in atherosclerosis
LDL
90
what investigation would you do to distinguish between intermittent claudication and spinal canal stenosis
MRI
91
how is an ankle brachial pressure index (ABPI) performed
doppler auscultates the brachial BP cuff is inflated until signal disappears doppler then placed at posterior tibial/dorsalis pedis BP cuff inflated (at ankle) until signal disappears
92
results of ABPI
the results are expressed as ratio (ankle:brachial) if 1- leg and arm are the same so normal if below 0.8- may have intermittent claudication (or no symptoms at all) if below 0.4- might have pain at rest and/or at night and tissue loss (suggests chronic limb-threatening ischaemia)
93
when would you offer angioplasty and stenting for intermittent claudication
after modifiable risk factors have been reinforced when supervised exercise programme has not lead to satisfactory improvement in symptoms imaging has proved that angioplasty is suitable
94
which 2 medications should be commenced with intermittent claudication
an antiplatelet- aspirin/clopidogrel statin (regardless of serum cholesterol levels)
95
how is angioplasty performed
needle punctures common femoral artery at groin level contrast dye is injected into artery to visualise stenosis/occlusion wire passed through diseased artery and ballon is passed over wire it is inflated in the diseased segment with widen blood flow
96
what to do if angioplasty doesn't work
can do bypass incisions are made over the arteries above and below the disease usually great saphenous vein is removed from the leg, reversed and stitched to the artery as an alternative conduct
97
does intermittent claudication progress to worse
1/3= symptoms resolve and unaffected 1/3= symptoms remain stable and do not progress 1/3= symptoms worsen (claudication distance decreases, lifestyle more impacted), can progress to critical limb ischaemia (rest and/or night pain)
98
what % of those with intermittent claudication have amputation
1%

Semester 2 (3rd year) (12 decks)

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