Signs and Symptoms in the Lower Limb Pain: Lower limb Varicose veins -> itching and aching Exercise related muscular cramp like pain or severe constant pain initially in the ties and foot -> obliterating arterial disease. Upper Limb Aching Swelling Intermittent claudication: Muscular pain on walking Pain at reproducible distance Worse on walking uphill Increases if patient continues to walk and patient begins to limb. Chronic ischemia with rest pain: Only 10% of claudication progresses to this, Very severe and burning pain. When there is a more severe obstruction. Felt also in the skin and soft tissues of the skin. Mostly at night because: Gravity assistance to arterial supply is lost Cardiac output decreases at rest Skin vessels dilate due to warmth Pain is relieved by hanging the leg of the bed etc or even by walking around. Pain is usually not relieved by any analgesics Patients often end up sleeping in a chair -> develops lower limb edema. Be aware of this in diabetic patients as the pain may be masked by diabetic neuropathy. Acute critical limb ischemia: Pain Pallor Pulselessness Perishing coldness -> usually at the most extreme of the foot. Perishing coldness Paraesthesia Paralysis Note that paralysis and anaesthesia are not present all the time. But if there, they are dire prognostic features are require urgent revascularisation. Distinguishing between different types of ulcers Cauda equina syndrome vs arterial insufficiency Cauda Equina Arterial Insufficiency Claudication History of lower back pain. Pain worse when walking uphill Sensory changes Pulses are affected Pain better after 15 to 30 minutes of rest Variable change in sensations Pain is not affected by uphill walking Temperature changes Pain improves with cycling Duplex ultrasound Evidence of LMN features=es ABI is affected CT or MRI imaging studies No history of backpain Pulses are usually present, and ABI is usually normal No evidence of LMNL. Colour Changes Warm and pulses present I contrast to arterial disease. White le fog pregnancy/phlegmasia alba dolens Blue leg/ phlegmasia A more serious variant Incipient venous infraction. Blue toes In severe claudication or rest pain Suggests foot is developing tissue necrosis -> pregangrene Black toes Chronic ischemia Patchy and localised if collaterals have been formed. Necrotic area slowly becomes hard, black and mummified -> dry gangrene If becomes infected -> wet gangrene -> NEEDS URGENT TREATMENT Redness Means that the issue oxygenation is present and there is no venous congestion or obstruction. Buerger’s test for severe ischemia If peripheral arterial blood pressure is inadequate to overcome gravity -> entire foot becomes white. Abnormal pigmentation Brown pigmentation -> chronic venous insufficiency May be in deep or superficial veins Due to a post reflux in the veins or post-thrombotic limbs Post venous reflux: Inflammation -> valves become incompetent Muscle pump is not enough to maintain Standing will cause: Venous strangulation Increased venous pressure in the legs Chronic leg swelling Red cells extravasate into the tissues-> form haemosiderin deposits -> brown pigmentation. This would be accompanied by dry, scaly, atrophic skin described as varicose or venous eczema Causes of Ulcerations Venous -> most common Complication of varicose veins or a late complication of DVT. Arterial Ischemic ulcers present early due to the intolerable pain Diabetes May present late, due to pain being masked by a neuropathy. Vasculitis Ulcerating tumours Infection rarely plays a role, but various tropic ulcers and TB are important causes in developing countries. Vary rarely squamous carcinoma develops longstanding ulcer and is recognised by proliferative change at the ulcer margin -> Marjolin ulcers More frequently flows a burn which fails to heal. Limb swelling Most unilateral causes are chronic and painless Except DVT and cellulitis Bifurcations affected in PAD Aorto-iliac Femoral-popliteal Tibiofibular bifurcation Other important notes Diabetic foot ulcers Present late: Patient don’t realise there is injury or that their shoes are poor fitting. Pressure ulcers Associated with poor mobility Arterial ulcers Pale due to poor blood supply Smaller and deeper Less likely to bleed Worse at night and when lying flat and when elevated leg Pain improves with lowering as gravity helps with circulation Venous ulcers At the gaiter area Associated with: Hyperpigmentation Venous eczema Lipodermatosclerosis After a minor injury Large and more superficial than arterial ulcers More likely to bleed Irregular boarders Management of arterial ulcers Does not involve debridement and compression Treated by treating the underlying disease Management of venous ulcers Referral Tissue viablbity Dermatology Pain clinic Diabetic ulcer services. Good wound care Cleaning Debridement Wound dresses Compression therapy Only after arterial ulcers have been excluded with a ABI Helps blood drain away from the leg and stops it from pooling in the leg Antibiotics and analgesics Avoid NSAIDs as it can make things even worse.