1. History & Examination of Extremities
M K ALAM

2. Components of extremities
Skin & subcutaneous tissue ( lumps, ulcers)
Arteries
Veins
Lymphatics
Nerves
Muscles, bones & joints (Musculo-skeletal system)

3. Arterial Disease

4. Presentations of arterial disease
Chronic ischemia:
Intermittent claudication: lower limb, arm pain
Rest pain: constant pain that occurs in the foot, relieved by dependency

5. Intermittent claudication
Muscle pain which appears following muscle use e.g.; after walking in lower limbs
3 criteria:
1. Pain in a muscle usually the calf
2. Pain develops only after muscle use
3. Pain disappears with rest
(Muscles of thigh, buttocks or arm may also be affected)

6. Acute ischemia:
Acute on chronic pain- thrombosis in atherosclerotic vessel
Acute pain of sudden onset- embolism from heart, aneurysm

7. Lower limb ischemia

8. Fingers/ toes discoloration - ischemia, Renaud’s phenomenon
Ulceration
Gangrene ( dead tissue) brown/ black, painless, no sensation, cold
Pulsatile mass

9. Radial artery aneurysm

10. History
Pain: Acute, acute-on-chronic, chronic- intermittent claudication
Site, severity,
Time taken for appearance and disappearance
Walking distance, progression,
Paresthesia (numbness, pins and needle)
Rest pain
Discoloration
Ulceration
Smoking

11. Systemic inquiry Symptoms indicating vascular disease elsewhere
Chest pain
Fainting
Weakness in limbs
Paresthesia
Blurring of vision
Other system inquiry- as in any other patient

12. PMH MI Stroke Diabetes Previous episode of claudication Dyslipidemia
Hypertension

13. Family history Genetic predisposition: Other family members may
be suffering from vascular disease

14. General examination ?Obese Pulse , Blood pressure
Full CVS evaluation- heart, carotid, abdominal aorta

15. Inspection of the extremity
Expose both limbs (lower or upper)
Skin color- shiny skin in ischemia
Pallor on elevation (vascular angle)
Rubor on dependency
Venous filling- guttering of veins in ischemia
Ulceration- tip of toes
Discoloration ?patches of gangrene
Pulsatile mass (femoral, popliteal)
Thickening of nail, loss of leg hair

16. Presentation of acute ischemia:
Five “P”
Pain
Pallor
Pulseless
Paresthesia
Paralysis

18. Ischemic foot

19. Upper limb ischemia

20. Palpation of the extremity
Temperature- colder limb in ischemia
Capillary refilling- normal 2-4 seconds
Pulses:
Carotid and abdominal aorta (part of general examination)
Upper limb:
Lower limb:

21. Palpation: Upper limb pulses
Axillary: in the axilla and medial upper arm.
Brachial: antecubital fossa immediately medial to the biceps tendon.
Radial: at wrist anterior to the radius.
Ulnar: on medial side of the wrist.

22. Lower limb pulses
Femoral: At midinguinal point (midway between the anterior superior iliac spine and the pubic tubercle)
Popliteal: Knee flexed to 45 degrees. Foot flat on the examination table. Bimanual technique Both thumbs are placed on the tibial tuberosity anteriorly and the fingers are placed into the popliteal fossa between the two heads of the gastrocnemius muscle and compressing it against the posterior aspect of the tibia just below the knee
Posterior tibial: 2 cm posterior to the medial malleolus.
Dorsalis pedis:1 cm lateral to the extensor hallucis longus tendon

23. Palpation of pulses
Pulse grading: 2+ normal palpable, but reduced; absent to palpation aneurysmal enlargement

25. Palpation Muscle wasting and power Nervous system: Motor Sensory
Reflexes

26. Auscultation Common sites for bruits: Carotid Aortic bifurcation Iliac
Common femoral

27. Venous disease

28. Venous disease Common presentations: Pain in lower limbs
Prominent veins
Lower limb swelling
Skin changes
Ulcer
Upper limb pain and swelling

29. Venous disease Venous diseases: Varicose veins.
Deep venous thrombosis.
Chronic venous insufficiency.
Venous ulcer.
Superficial thrombophlebitis.
Upper limb pain and swelling.

30. Lower Extremity Veins
Superficial veins: Greater saphenous vein (GSV) Lesser saphenous vein (LSV) and their tributaries.
The GSV- from the dorsal pedal venous arch and courses cephalad and enters the common femoral vein approximately 4 cm inferior and lateral to the pubic tubercle.
The LSV- originates laterally from the dorsal pedal venous arch and courses cephalad in posterior calf to join the popliteal vein

31. Lower Extremity Veins Deep veins follows arteries- Popliteal, femoral
Multiple perforator veins traverse the deep fascia to connect the superficial and deep venous systems.
Unidirectional blood flow is achieved with multiple venous valves

33. History Varicose veins: - Dull pain
- No pain during rest or early in the morning
- Exacerbated after prolonged standing

34. History Deep Vein Thrombosis: - Post-operative.
- Immobility due to other illness.
- Leg pain.
- Leg swelling.

35. History of risk factors for DVT
Female
Increased age
Previous thromboembolism
Malignancy
Trauma
Obesity
Pregnancy
Post-operative state
Prolonged recumbency

36. History Chronic venous insufficiency:
- Post DVT or venous reflux ( VV).
- Aching pain on exertion.
- Bursting feeling on walking.
- Leg swelling.
- Eczema , ulceration.

37. History Superficial thrombophlebitis: Venous ulcer:
Inflammation & thrombosis of previously normal superficial vein.
Pain, redness and cord like vein
Venous ulcer:
Previous DVT , VV
Above medial (70%) or lateral malleolus

38. Remaining history as any other patient
Family history of varicose veins
Use of contraceptive pills

39. Inspection Both lower limb exposed & compare
Supine & standing (for varicose veins)
Look for varicose veins ( anterior & posterior)
Document the venous system involved
Calf or whole limb swelling (duration)
Localized swelling and skin changes in superficial thrombophlebitis in the line of superficial vein

41. Inspection
Features of chronic venous insufficiency (CVI): Oedema, leg induration, pigmentation, eczema, ulceration, skin thickness & redness- lipodermatosclerosis
Ulceration: Venous ulcers are located around medial lower 1/3rd of the leg noting size, shape, margin and floor

44. Palpation Temperature: warm (DVT, infection)
Tense and tender calf (DVT)
Homan’s sign- stretching calf by foot dorsiflexion causes pain
Pitting edema
Skin thickening, redness
Cord like superficial tender swelling (sup. thrombophlebitis)

45. Palpation
Tapping the venous column demonstrates pressure transmission to incompetent distal veins.
Coughing impulse at sapheno-femoral junction denotes incompetent valve

47. Trendelenburg test Patient's leg elevated to drain venous blood.
An elastic tourniquet applied at the sapheno-femoral junction
The patient then stands with tourniquet in place.
Rapid filling (<30 seconds) of the great saphenous system- perforator valve incompetent.
No filling- perforators are competent
Now release the tourniquet
Filling of the great saphenous system from above- sapheno-femoral valve is incompetent.

48. Auscultation
Over large veins- murmur in arterio-venous fistula ( veins do not collapse on lying down and can feel pulsation and thrill during palpation)

49. Lymphatic disease

50. Lymphatic disease Infection: Pain, swelling of acute onset
Lymphedema: Chronic extremity swelling

51. Infection- lymphangitis
Inspection: Red streaks and swelling of the limb
Site of primary infection may be visible
Spreading
Palpation: Warm, tender, pitting oedema
Palpable and tender draining lymph node

53. Lymphedema

54. Lymphedema Interstitial oedema of lymphatic origin
Primary lymphedema: Congenital, due to poorly developed lymphatics
Secondary: Infective (Filariasis) or neoplastic (secondary deposits)

57. History
Age of onset:
Primary: congenital- from birth, early life- praecox, late in life- tarda)
Secondary: middle to old
Gender: F> M
Nationality: Filariasis in tropical areas

58. History Slowly progressive swelling ( LL> UL) Painless
PMH: malignancy, radiotherapy, recurrent infection,
Surgery: lymph node excision
Family history: primary type can be familial

60. Examination
Inspection: Unilateral swollen limb, swollen foot in lower limb , toe usually spared
Palpation: Initially pitting, later non-pitting due to fibrosis, thickened skin, hair loss, hyperkeratotic, scaly
Draining lymph nodes: Primary lymphedema- not enlarged. Malignancy- enlarged or excised

61. Examination Complete examination of the patient
Absence of renal, cardiac, abdominal and venous diseases helps in the diagnosis of lymphedema

62. Foot Lesions

63. Foot Lesions History and examination like a lump or ulcer patients
History: Duration, pain, progress, trauma, h/o diabetes, other illness
Examination of the lesion, surrounding area, lymph nodes, pulses, temperature, tenderness, sensation, motor function

65. Madura Foot

69. Thank you!