SWOLLEN LEG Belen Carsi

Transcription

1 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

2 >190 Commence LMWH and assess for ambulatory management b. Medium or high risk; book venogram. Assess for ambulatory management 4. 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 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.

3 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

4 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. A P P E N D I X 1 R I S K S T R A T I F I C A T I O N F O R D V T SCORE HISTORY: Paralysis / paresis / plaster immobilisation of lower limbs +1 Bedridden >3 days, major surgery in <4/52, airline flights >4 hours Active cancer Rx in previous 6/12 or on palliative treatment /E 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 SCORE HIGH >3 MODERATE 1 2 LOW <0

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