painful swollen limb

Painful swollen limbPainful swollen limb

CaseCase

A 28-year-old women was seen by her family physician for routine pregnancy check-up at 36 weeks gestational age. Neither the patient nor the physician had any concern about the pregnancy. However patient did complain of the unilateral swelling of her left leg, which has gradually increased over the previous 2 days. Furthermore, evening before her visit she developed some sharp chest pain, which was exacerbated by deep breaths.

LEGLEG

Part of the lower limb between the knee joint and ankle joint

Major structures pass throughProximal------popliteal fossaDistal------------Tarsal tunnel

LegLeg

Bony Framework

Interosseous membraneInterosseous membrane

Leg CompartmentsLeg Compartments

• Muscles in the anterior compartment of leg dorsiflex the ankle, extend the toes, and invert the foot.

• Muscles in the posterior compartment plantarflex the ankle, flex the toes, and invert the foot.

• Muscles in the lateral compartment evert the foot.

• Major nerves and vessels supply or pass through each compartment.

Superficial group of muscles in Superficial group of muscles in the posterior compartment of legthe posterior compartment of leg

Deep group of Deep group of muscles in the muscles in the

posterior posterior compartment compartment

of leg.of leg.

Arteries in Arteries in the the

posterior posterior compartmecompartme

nt of leg.nt of leg.

Tibial nerveTibial nerve

Muscles in Muscles in the lateral the lateral

compartmecompartment of legnt of leg

Muscles of Muscles of the anterior the anterior compartmecompartme

nt of legnt of leg

Common conditions affecting Common conditions affecting the Legthe Leg

Peripheral neuropathy (particularly associated with diabetes mellitus)

Lumbar nerve root lesions (associated with pathology of the intervertebral discs)

Fibular nerve palsy

The deep and superficial veins of the legsThe deep and superficial veins of the legs

The veins of the legs are divided into two systems

– the deep veins (which run deep to the leathery layer of fascia surrounding the muscles) and

– the superficial veins (which run in the layer of fat just beneath the skin).

The superficial veins are the ones that you can see (for example, on your foot or around the ankle) and they are the ones that can become varicose.

VENOUS SYSTEM (LOWER LIMB)

I- Superficial System: (Superficial to deep Fascia).

1- Long saphenous vein: start 1cm above and anterior to the medial malleolus and pass through the antero-medial aspect of the leg and thigh to open into the femoral vein through the saphenous opening.

2- Short saphenous vein: start above the ankle joint in the post. aspect of the leg midway between lateral malleolus and tendoachilis & end in the popliteal vein with variable course.

II. Deep system: Veins in the soleus muscle Ant. & post. tibial veins in the leg form the popliteal vein which is the major tributary to the femoral vein.The deep system lies deep to deep fascia.

III- Communicating system:Perforating veins communicating between sup & deep systems:1- At Saphenofemoral junction.2- At the middle of the thigh.3- Just above the knee.4- Just below the knee.5- Just above the ankle.

DEEP VENOUS DEEP VENOUS THROMBOSISTHROMBOSIS

(DVT)(DVT)

DEFINITIONDEFINITION Deep vein thrombosis (DVT) is a medical condition in

which blood clots form within the large veins of the body, such as the calves and thighs, or also sometimes in the pelvis, chest, or arms.

These blood clots impede the circulation of blood and nutrients to the limbs, as well as to various organs and body systems. Such clots may become very dangerous if they break off because they can travel to another part of the body such as the lungs, brain, or heart and block circulation to that organ.

This may result in severe tissue damage and create a life-threatening situation if the clot is left untreated.

Causes of DVTCauses of DVT

age - as people over 40 are at greater risk of DVT a past history of DVT a family history of DVT an inherited condition that makes the blood more likely to clot than usual1 immobility obesity recent surgery or an injury, especially to the hips or knees Pregnancy, having recently had a baby having cancer and its treatments taking a contraceptive pill that contains estrogen - but most modern pills

contain a low-dose, which increases the risk by an amount that is acceptable for most women

hormone replacement therapy (HRT) - but for many women, the other benefits outweigh the increase in risk of DVT

treatment for other circulation or heart problems

DVTDVT

PATHOGENESISPATHOGENESIS

CLINICAL FEATURESCLINICAL FEATURES

DUPLEX SCANDUPLEX SCAN

TREATMENTTREATMENT

Compression

Elevation

Immobilization

Anticoagulation

COMPLICATIONS COMPLICATIONS

VENOUS DISEASESVENOUS DISEASES

ANATOMY ANATOMY OF OF

SAPHENOUS VENOUS SAPHENOUS VENOUS SYSTEMSYSTEM

VALVES AND PERFORATORSVALVES AND PERFORATORS

VALVES IN THE VEINSVALVES IN THE VEINS

MUSCLE PUMPMUSCLE PUMP

MECHANISM OF VALVESMECHANISM OF VALVES

DefinitionDefinition

The term ’varicose vein’ refers to veins that are abnormally large and tortuous. This term applies to both the large protruding veins within the superficial subcutaneous fascia and the smaller ”spider veins” that occur just beneath the epidermis

Why do veins become varicose? Why do veins become varicose?

Who gets varicose veins?Who gets varicose veins?

Sex– Among the general population in the Western World,

about 20 to 30 per cent of women have varicose veins.

Age– More people develop varicose veins as they get older

– at least up to the age of about 60.

Heredity– It is not unusual for varicose veins to ‘run in the

family’ to some extent, but there is no well-proven genetic basis for varicose veins.

Height and weight

Pregnancy

Diet and bowel habit

Occupation and posture

What trouble do varicose veins What trouble do varicose veins usually cause?usually cause?

(Signs and Symptoms)(Signs and Symptoms)

Cosmetic embarrassmentCosmetic embarrassment

This is by far the most common problem that varicose veins cause, and is perfectly understandable in a society that makes women want to have nice looking legs.

Ankle swellingAnkle swelling

Varicose veins can cause ankle swelling in a few people, as the pressure in the veins causes fluid to be squeezed out into the tissues as they stand, sit with their feet on the ground or walk about. The swelling goes away after a night in bed.

Varicose veins can cause more Varicose veins can cause more serious chronic problemsserious chronic problems

Venous eczema (‘varicose Venous eczema (‘varicose eczema’)eczema’)

The first sign of trouble is often mild eczema and itchiness of the skin – usually just above the ankle.

This can be just a small patch, or a larger area.

Venous EczemaVenous Eczema

ULCERSULCERS

ARTERIAL DISEASESARTERIAL DISEASES

ATHEROSCLEROSISATHEROSCLEROSIS

PATHOGENESISPATHOGENESIS

PATHOGENESISPATHOGENESIS

ARTERIOGRAMSARTERIOGRAMS

Definition:An increased pressure within enclosed

osteofascial space that reduces capillary per-fusion below level necessary for tissue viability; the underlying mechanism is:

- increased volume within space- decreased space for contents- combination of both

EtiologyEtiology

Trauma with bleeding/swellingBleeding disordersBurnsTight wrapsTractionSurgical positioningPneumatic antishock garmentReprefusion swelling

Pathophysiology:Increased compartment pressure

leadsto increased venous pressure which decreases A-V gradient resulting in muscle and nerve ischemia.

Clinical DiagnosisClinical Diagnosis

The six ‘Ps’:– Pressure– Pain– Paresthesia– Paralysis– Pallor– Pulselessness

Leg Single Incision TechniqueLeg Single Incision Technique

Leg Two Incision TechniqueLeg Two Incision Technique

This picture shows a red and swollen thigh and leg caused by a blood clot (thrombus) in the deep veins in the groin ( compression of the left external iliac veins by the gravid uterus was the likely cause of stasis which lead to deep venous thrombosis