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Junior Surgery > Leg Pain And Ulcers > Flashcards

Leg Pain And Ulcers Flashcards

(70 cards)

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1
Q

What is PVD

A

Peripheral vascular disease
Narrowing or occlusion of the peripheral arteries affecting the blood supply to the lower limbs

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2
Q

Risk factors for PVD

A

Same as for IHD
- age
- smoking
- hypertension
- hyperlipidaemia
- diabetes

Rarely can be due to inflammatory disorders

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3
Q

What is the Fontaine classification and what is it used for

A

Outlines the typical progression of chronic lower limb PAD

  1. Asymptomatic
  2. Intermittent claudication
  3. Ischemic rest pain
  4. Ulceration / gangrene
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4
Q

What is the initial investigation to screen for arterial disease

A

ABPI
Ratio of the BP of the upper arm and lower limb
ABPI <0.8 - arterial disease
ABPI <0.4 - critical limb ischaemia

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5
Q

What does ABPI >1.2 suggest

A

May be a false negative due to calcification giving abnormally stiff vessels
Common in diabetes

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6
Q

Pathophysiology of intermittent claudication

A

Most commonly affects the calf as it is the femoral artery that most commonly becomes atheromatous
Exercise produces an oxygen demand that can’t be met and cold muscles become ischameic
This is relieved on rest

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7
Q

Symptoms of intermittent claudication

A

Ischaemic cramping pain on walking, relieved by rest
Pain reproducible at a similar level
Most commonly in the calf suggesting femoral disease
Pain in the thigh / buttock suggests ileal disease

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8
Q

Signs of intermittent claudication

A

Absent pulses
Cold pale legs
Atrophic hairless and shiny skin - chronic arterial insufficiency
Buerger’s angle <20 degrees
Arterial ulcers

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9
Q

What is ischaemic rest pain indicative of

A

Critical lower limb ischaemia

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10
Q

What is ischaemic rest pain

A

Occurs at night due to decreased effects of gravity and decreased BP reducing perfusion
Pt wakes from pain
Severe pain in forefoot
Can be relived by moving foot or walking on cold floor

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11
Q

What does ischaemic rest pain lead to

A

Ulcers from minor injuries as healing is impaired and if these get infected can lead to rapidly spreading gangrene

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12
Q

What is wet gangrene

A

Infected with proliferating organisms
Moist appearance, gross swelling and blistering

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13
Q

What is dry gangrene

A

Colonised but organisms are not proliferating
Hard, dry texture occurring in the distal toes and gingers
Often a clear demarcation between visible and black necrotic tissue

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14
Q

Management of wet gangrene

A

Is a surgical emergency
Requires urgent debridement to control spreading infection
Broad spectrum IV abx

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15
Q

What does presence of gangrene suggest

A

Threatened limb
ABPI <0.4
Requires surgical intervention

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16
Q

Conservative Management of PVD

A

Generally conservative
- smoking cessation, weight loss, exercise
- orthotics - raiding heel of shoe to decrease calf work
- foot care to prevent minor trauma
- optimise BP: avoid B blockers and diabetes

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17
Q

Medical management of PVD

A

Antiplatelet (clopidogrel) and statin
Management of diabetes

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18
Q

Surgical management of PVD (used if ABPI <0.6 or conservative insufficient)

A

Percutaneous transluminal angioplasty
- arterial catheter guided from femoral artery to diseased area and balloon inflated in narrowed segments
- effective for short segments of stenosis but risky

Bypass grafting
- for longer segments

Sympathectomy
- pain relief

Amputation

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19
Q

Risks of percutaneous transluminal angioplasty

A
  • emboli formation and distal ischaemia
  • iatrogenic arterial dissection
  • anaphylaxis to contrast medium used
  • AKI secondary to contrast medium used
  • haemorrhage
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20
Q

Benefits of amputation

A

May relieve intractable pain and prevent death from septicaemia

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21
Q

How to prevent phantom leg pain

A

Start neuropathic pain agent eg gabapentin pre amputation

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22
Q

Causes of an acutely ischaemic limb

A

Thrombus - rupture of atherosclerotic plaque leads to platelet aggregation and acute thrombosis
Embolus
Trauma

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23
Q

Predispositions for thrombosis (virchows triad)

A
  1. Endothelial dysfunction (trauma, inflammation, atheroma)
  2. Changes in blood flow: stasis or slow flow
  3. Changes in blood coagulability: inflammatory response / congenital causes
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24
Q

What is embolic occlusion

A

Occlusion of a vessel by a mass of material transported in the bloodstream
- usually a fragment of a thrombus

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25
Where can thromboemboli arise from
Left atrium in AF Left ventricle post MI Heart valves in endocarditis Aorta in AAA
26
Clinical symptoms of acutely ischaemic limb (6P’s)
Pulseless Painful Pallor Perishingly cold Paralysis Paraesthesia
27
Clinical features of an embolus
Sudden onset Very Severe symptoms due to lack of collaterals Normally an identifiable source eg AF or AAA Normal pulse history No history of arterial disease
28
Clinical features of a thrombosis
Insidious onset Less severe symptoms as advanced collaterals No obvious source Long standing decreased pulses bilaterally Previous history of IC, stroke, MI etc
29
Management of acutely ischaemic limb
Max 6hrs to re-establish flow A-E resus IV heparin Assessment of limb: - no blood supply = surgery - if obstruction is resolving = thrombolysis Urgent CT angiogram If leg is not thought to be viable, amputation may be only treatment option
30
Embolic occlusion in acutely ischaemic limb management
Open embolectomy Interval investigation into the underlying cause eg AF / AAA
31
Thrombotic occlusion management in the acutely ischaemic limb
Intra-arterial thrombolysis to restore vessel patency Interval angioplasty to treat underlying disease
32
Presentation of diabetic peripheral vascular disease
Sensory neuropathy - reduces protective reactions to minor injuries and reduces awareness of symptoms of infection / ischaemia Autonomic neuropathy - lack of sweating leads to dry, fissured skin allowing entry of bacteria Motor neuropathy - wasting of the small muscles of the foot lead to loss of the arches and development of abnormal pressure areas Red and hot with strong pulses
33
Transfemoral and transtibial leg amputations
Transfemoral = above knee Transtibial = below knee
34
Goal of lower limb amputation
Amputate at the most distal level that will remove the diseased tissue but preserve residual limb length creating best environment for return of mobility and function
35
Outcome of Transfemoral amputation vs transtibial
70% of trans-tibial amputees will walk 40% of trans-femoral
36
Complications of lower limb amputation
Non healing stump wound - occurs if amputation is too distal and underlying disease is still active Stump pain Phantom pain - occurs in 55-85% Psychological - 75% experience low mood / anxiety
37
What does suitability for prosthetic rehabilitation depend on
Cognitive ability Motivation Expectation Goals Physical strength Co-morbidities
38
Associated complications of lower limb amputation
Pressure sores Skin rashes Allergies Neuroma development Contralateral joint issues Poor patient acceptance
39
What is the difference between the superficial and deep venous systems
Deep venous system comprises a number of veins that accompany the major lower limb arteries - drains the muscular compartment of the leg Superficial venous system comprises the medial long saphenous vein which drains to the saphenofemoral junction and the lateral short saphenous which drains popliteal vein - drains the skin and superficial tissues
40
Where do the deep and superficial venous systems join
Saphenofemoral and saphenopopliteal junction
41
Define varicose veins
Abnormally dilated and lengthened superficial veins
42
Pathophysiology of varicose veins
Valvular insufficiency in the superficial veins leads to primary varicose veins whereas valvular insufficiency in the deep veins leads to deep venous insufficiency and secondary varicose veins
43
What are primary varicose veins
2x as common in women with pregnancy accentuating symptoms Likely due to primary superficial valve defect with familial elements Surgical treatment possible
44
What are secondary varicose veins
Superficial varicosities develop secondary to deep venous insufficiency - calf pump can no longer efficiently return blood to the thoracic cavity due to valve failure in the deep venous system - high pressure in deep venous system leads to perforator vein incompetence and resultant back flow to superficial venous system
45
Causes of secondary varicose veins
Previous DVT as valves remain incompetent Raised systemic venous pressure - due to large vein compression, arterio-venous fistula or severe tricuspid incompetence Congenital absence of valves (rare)
46
Clinical features of deep venous insufficiency
- lower limb aching pain / discomfort - oedema of lower leg - superficial varicose veins - haemosiderin deposition in gaiter area - eczema / pruritis - atrophie blanche - lipodermatosclerosis - inverted champagne bottle - ulceration
47
Symptoms of varicose veins
Unsightly appearance Itching Nocturnal cramps Oedema of ankles Dull ache to leg Signs of deep venous insufficiency
48
Investigations for varicose veins
Hand held Doppler - identifies reflux at saphenofemoral / saphenopopliteal junctions Duplex scanning - can diagnoses valvular and perforation vein incompetence as well as large vein occlusion - can confirm deep venous insufficiency Venography - contrast injected into superficial vein of foot. Fluoroscopy used to see progress through deep vein system
49
Management of varicose veins
Avoid prolonged standing, exercise, weight loss Graded compression stockings - first exclude arterial disease with ABPI If dilated, haemorrhage, deep venous insufficiency then consider: - endothermal ablation - sclerotherapy - surgery
50
What is endothermal ablation for varicose veins
Laser fibre passed along the vein (USS guided) And then fired to cause heat and endothelial ablation leading to vein thrombosis
51
What is sclerotherapy for varicose veins
Used for cosmetically undesirable varicosities Chemical sclerosant injected into an empty vein and the vein is kept compressed for 2 weeks to allow fibrosis to take place
52
Describe surgery for varicose veins
Gold standard - great saphenous vein is disconnected from the femoral vein - any incompetent perforators are individually ligated
53
Complications of varicose veins
Haemorrhage: caused by minor trauma to a dilated vein Phlebitis: can occur spontaneously or following sclerotherapy - veins become hard and tender with overlying erythema - may be systemic upset
54
What is lymphoedema
Progressive disorder of the lymphatic system that results in accumulation of interstital fluid and fibroadipose tissue Blockage to normal lymphatic drainage routes cause chronic non pitting oedema
55
How to differentiate between intermittent claudication and spinal claudication
Intermittent is worse walking uphill Spinal would be worse walking down hill
56
What is primary lymphoedema
Presents in early life Secondary to an inherited deficiency of lymphatic vessels Most commonly affects the legs and progresses with age
57
What is secondary lymphoedema
Obstruction of lymphatic vessels Usually due to malignancy or cancer related therapy eg radiotherapy or lymph node dissection
58
Diagnosis of lymphoedema
Usually clinical after other causes of oedema have been excluded eg CCF, renal disease, deep venous insufficiency Specialist centres can use lymphoscintigraphy
59
Management of lymphoedema
Elevation of limb Compression stocking Physical massage Long term abx for recurrent cellulitis
60
What is Raynaud’s phenomenon
Episodic digital vasospasm in the absence of an identifiable associated disorder Most commonly presents in 15-30 year old females with FH Thought to be an exaggerated response of the physiological vasospasm process Brought on by cold or emotional stress
61
What are the 3 phases of Raynaud’s phenomenon
1. Pallor: due to digital artery spasm 2. Cyanosis: due to accumulation of deoxygenated blood 3. Rubor: erythema due to reactive hyperaemia
62
What is raynaud’s syndrome
Raynaud’s phenomenon secondary to another condition that causes peripheral vasospasm
63
What conditions can cause peripheral vasospasm
Connective tissue disorders: - systemic sclerosis, SLE, sjorgens syndrome, polyarteritis nodosa Macrovascular disease - atherosclerosis, thoracic outlet obstruction, buerger’s disease Occupational trauma - vibration white finger, repeated extreme cold or chemical exposure Drugs: - B blockers or cytotoxic drugs Others: - malignancy, AVF
64
What is venous duplex US used for
Is the investigation of choice for varicose veins / chronic venous disease - shows retrograde venous flow
65
Management of peripheral arterial disease
Clopidogrel 75mg Atorvastatin 80mg
66
Clinical features of venous ulcers
Brown pigmentation Lipodermatosclerosis (champagne bottle legs) Eczema
67
ABPI value for critical limb ischaemia
0.3
68
ABPI value for hyperaemia and severe vascular disease
0.5
69
Management for superficial thrombophlebitis
Compression stockings (If arterial insufficiency has been excluded)
70
What is the screening programme for AAA
Single abdominal ultrasound for males aged 65

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