Download SWOLLEN LEG Belen Carsi BACKGROUND We exclude from this

SWOLLEN LEG
Belen Carsi
BACKGROUND
We exclude from this topic bilateral swelling as this may be caused by fluid retention
caused by heart, liver or kidney failure.
Usual causes of unilateral oedema include
trauma (fractures, contusions), cellulitis, osteomyelitis, ruptured Baker's Cyst, deep vein
thrombosis (DVT), compartment syndrome and occasionally lymphatic obstruction.
PRESENTATION
Firstly, it is necessary to distinguish new or worsening symptoms from chronic swelling.
Acute leg swelling usually occurs secondary to an injury except in DVT. DVT and
compartment syndrome are potentially life/limb threatening while the other causes of leg
swelling may resolve without sequelae.
DIFFERENTIAL DIAGNOSIS
• DVT (positive D-Dimer, Doppler or venogram).
• Compartment syndrome (excruciating pain, compartment pressure >30mmHg).
• Contusion of calf muscles (direct blow, subsequent ecchymosis and tenderness).
• Ruptured popliteal cyst (no history of prior trauma or surgery).
• Cellulitis (erythema, superficial tenderness).
• Osteomyelitis (pain, CRP, ESR, bone changes on x-ray or MRI).
• Lymphoedema (non-tender, diffuse swelling).
DVT
Venous thromboembolism (VTE), specifically deep vein thrombosis and pulmonary
embolism, are prevalent in ambulatory care and in-patient medical or surgical patients.
Without prophylaxis, 24% patients develop DVT after MI and 60% after strokes. In surgical
patients the incidence varies from 59% after hip operations, 29% after general surgery or
11% after prostate surgery. Primary risk factors are major surgery, MI, major trauma,
paralytic stroke, cancer, spinal cord injury and pelvic fracture. Secondary factors are CHF,
previous DVT, immobilization, obesity, chronic respiratory failure, increasing age,
haematological disorders, varicose veins, pregnancy, oestrogen treatment, central venous
catheter and hospitalization.
The diagnosis is challenging as typical signs are often missing. The classic sings of DVT
are calf (or thigh) tenderness, swelling, increased warmth, palpable cord and a positive
Homans sign (ie, pain on passive dorsiflexion of the foot).
Trust Guidelines for diagnosis and treatment of DVT include a Risk Stratification Score
(Wells score), flow chart for managing a patient that presents to A&E with a suspected
DVT, enoxaparin doses, outpatient treatment protocol and contact numbers for
anticoagulation nurses (bleep 1845/0049) booking Doppler (ext.1521) or venogram (ext.
1389). The full version of the protocol may be found in the Emergency department (Minors
Area). In short:
1. IVDA; book Doppler ( Ext.1521) and admit for treatment if positive
2. Previous VTEor known thrombophilia; book venogram (fax 1389, tel 2491 or 1589)
Assess for ambulatory management and admit (medics) if unsuitable
3. All others; perform risk stratification score
a. Low Risk; D.dimer <190 DVT ruled out
>190 Commence LMWH and assess for ambulatory
management
b. Medium or high risk; book venogram. Assess for ambulatory management
Bloods; FBC, U&E, LFTs and clotting in all medium and high risk . Thromboplhilia
screen for young (<45 years) and first episode of VTE, Positive family history,
recurrent episodes VTE, large or unusual thrombosis, recurrent miscarriages
5. Ambulatory management
a. Exclusions; Suspected, current or known previous PE, pregnancy, serious
concomitant illness, chemotherapy, bleeding disorder, severe hypertension,
IVDA, social reasons, not resident in St Helens or Knowsley.
b. Procedure; commence LMWH, dispense sufficient to cover till next working
day, Place notes, OPD treatment form and Venogram request form in ‘DVT’
box in A&E reception. Call and leave message for anticoag nurses ext. 1845
4.
COMPARTMENT SYNDROME
Characterized by acute leg pain and swelling, it usually occurs following an injury. It is a
very important differential diagnosis as may leave permanent sequelae. It is a limbthreatening condition. Compartment syndromes are characterized by an elevation of
intracompartmental pressure to a degree that compromises blood flow to the involved
muscles and nerves. Although most often encountered after tibial fractures, they may
follow any condition that has the potential to cause significant swelling such as contusions,
muscle strains or crush injuries. There are four compartments in the leg: anterior, lateral,
posterior, and deep posterior. The syndrome may affect one or more of the four
compartments although the anterior is the most frequently involved.
The hallmark
symptom of an acute compartment syndrome is severe leg pain that is out of proportion to
what would otherwise be expected. As the condition progresses, patients also experience
paraesthesia or numbness of the foot. Increased pain with passive stretching of the
muscles involved is characteristic. Anterior compartment involvement causes pain when
flexing the great toe (EHL), lateral compartment pain is elicit on inversion of the foot (PL
and PB) and deep compartment causes pain when extending the great toe (FHL). Parlor
and pulselesness are late signs.
Clinically significant compartment syndrome is present when diastolic pressure –
compartment pressure = o < 30 mmHg. This is a surgical emergency. Failure to diagnose
and immediately treat a compartment syndrome can result in tissue necrosis and
permanent muscle contracture, pain, weakness, and neurologic injury. Always refer to
Orthopaedics.
CONTUSIONS
Contusions are injuries to the leg sustained from a direct blow. Although the resulting
disability usually is minor, contusions can be quite painful, with significant swelling and
tenderness. Excessive swelling can ultimately result in a compartment syndrome.
Contusions are treated with rest, elevation, ice and minor analgesics. Most do not need
follow-up.
RUPTURE OF POPLITEAL CYST (BAKER’S CYST)
Usually occurs in older patients with degenerative arthritis or rheumatoid arthritis. Fluid
from the cyst can extravasate down the leg and over 24 hours cause diffuse calf pain and
swelling. The condition can closely mimic DVT. The patient will have no history of trauma.
Usually, patients have been diagnosed as having a popliteal cyst in the past, or they have
noticed an uncomfortable fullness in the popliteal fossa. Although usually not necessary,
MRI can help confirm the presence of a ruptured popliteal cyst by showing both the cyst
and fluid extravasation. Ruptured popliteal cysts are treated symptomatically with minor
analgesics, rest and elevation. Long-term treatment is directed at the aetiology of the
popliteal cyst. Refer to Fracture Clinic/Orthopaedic Outpatients.
CELLULITIS
It is a common infection of the skin and the soft tissues underneath the skin. It occurs
when bacteria invade broken or normal skin and start to spread under it. This results in
infection and inflammation. The skin is painful, red, and tender. Patients may experience
fever and chills indicating bacteraemia. Lymph nodes may be swollen. The skin may be
blistered and then scab over. Pus discharge indicates a draining abscess.
Patients at risk for cellulitis are those with trauma to the skin (including surgery) or other
medical problems such as diabetes, lymphoedema or skin disorders. The most common
aetiology is Streptococcus pyogenes. Staphylococcus aureus is usually associated with
an open wound. Haemophilus can be the aetiology in children. With tissue necrosis,
gram-negative bacilli can be involved (E. coli, P.aeruginosa). Cellulitis occurring after
animal bites can be caused by unusual bacteria, especially Pasteurella multocida from
dogs and cats. The responsible organism often is difficult to isolate unless pus has
formed.
Ordinarily, mild cases of cellulitis can be treated with oral Penicillin or
Cephalosporin. Patients with high fever, systemic toxicity or poor host resistance should
be admitted for IV antibiotic therapy. Follow Trust Antibiotic Policy. Consult Microbiologist
if advice is required. In diabetics with poor control, consult diabetic nurses/ consultant
diabetician.
Necrotizing fascitis is a serious soft tissue infection generally caused by Group A
Streptococci. This infection results in extensive soft tissue destruction of skin,
subcutaneous tissue and muscle. Early clinical findings may include an area with minimal
erythema and swelling, with rapid progression of tenderness out of proportion to the
clinical appearance of the wound. Subcutaneous gas may be present radiographically on
soft tissue films before crepitus can be appreciated on exam. Often surgical intervention in
combination with antibiotic therapy is required. Mortality rate is high (>70%) particularly if
treatment is delayed. Infection is often the result of a skin abrasion or puncture that
becomes infected with Streptococcal bacteria. Involve seniors and consult plastics if
suspected.
OSTEOMYELITIS
See appropriate chapter.
LYMPHATIC OBSTRUCTION
When a lymph vessel is obstructed there is an accumulation of lymph distal to the
obstruction called lymphoedema. The amount of resultant swelling and the size of the
area affected depend on the size of the vessel involved. Lymphoedema usually leads to
low-grade inflammation and fibrosis of the lymph vessel. The most common causes in the
UK are tumours and surgery. In other parts of the world parasitic infections can be a cause
of severe forms of lymphoedema. Filariasis is an example of this and it is common in
Africa resulting in the condition known as elephantiasis. This is caused by parasitic
infection by a nematode worm which inhabit the lymphatics causing blockage and is
transmitted to humans via mosquitoes. Lymphoedema has no cure. Mild cases can
improve with compression bandages. Contact medics or surgeons depending on the
suspected cause.
APPENDIX 1
R I SK ST RATI F I C ATI O N
FOR
DVT
SCORE
HISTORY:
0/E
SCORE
Paralysis / paresis / plaster immobilisation of lower limbs
+1
Bedridden >3 days, major surgery in <4/52, airline flights >4 hours
+1
Active cancer – Rx in previous 6/12 or on palliative treatment
+1
Entire leg swollen
+1
Calf swollen >3 cm than other leg (10 cm below tibial tuberosity)
+1
Tenderness along deep veins
+1
Pitting oedema worse in symptomatic leg
+1
Collateral superficial veins (non-varicose)
+1
Alternative diagnosis more likely than DVT
-2
HIGH
>3
MODERATE
LOW
1–2
<0
APPENDIX 2