Lower Leg Swelling

Atherton Sorrenti, Kent Clark, Lee Hardin

Lower Leg Swelling

Leg swelling generally occurs because of an abnormal accumulation of fluid in the tissues of the lower extremity. The medical term for leg swelling from excessive fluid in the tissues is edema. Persisting indentation of a swollen leg after pressure from a finger is known as pitting edema.

Less common causes of leg swelling include diseases that cause thickness of the layers of skin, such as scleroderma and eosinophilic fasciitis. In these diseases, the leg swelling is characterized by non-pitting edema.

REFERENCE:Fauci, Anthony S., et al. Harrison's Principles of Internal Medicine. 17th ed. United States: McGraw-Hill Professional, 2008.

Bilateral Systemtic Condition CHF Liver/Kidney Na+ Imbalance Lymphedema Diabetes Drugs Tumor/Space Occupying

Lesion (proximate)

Unilateral DVT Muscular Sprain/Strain Compartment

Syndrome Tumor/Space

Occupying Lesion

Bilateral vs. Unilateral

CHF

Liver/Kidney

Na+ Imbalance

Lymphadema

Tumor/Space Occupying Lesion

Diabetes

Drugs

Deep Vein Thrombosis

Compartment Syndrome

Possible Causes of LLS

Baker CystCellulitisCirrhosis (liver)Congestive Heart FailureEosinophilic FascitisPhlebitisSclerodermaDVT

Possible Causes of LLS Continued

Idiopathic EdemaLeg Vein ObstructionMedicationsNephrotic SyndromeSalt RetentionTrauma InjuryCompartment Syndrome

Source: Medicinenet

How to take a good patient history

Obviously, height, weight and vitals

Determine unilateral or bilateral swelling

This will help narrow your differential list

Unilateral vs Bilateral

If Unilateral Swelling?Determine the following:

Involved traumaHistory of contraceptive use or

immobilizationDetermine whether there was a

sudden or gradual onset of pain w/ exercise

Unilateral DDX

DVTMuscle tearAnterior compartment syndromeBaker’s cyst/ popliteal cystTumorsFractures

Unilateral vs Bilateral

Bilateral swelling? Determine the following:

Age at onsetCardiopulmonary statusDrug and food consumption that

may cause salt retention.Hours a day pt standsVaricosities in leg.

Bilateral

CHFlymph blockage that may occur

with tumorsVenous insufficiencyLiver pathologyKidney pathologyObesityHyperthyroidism

History

Onset Acute/ chronic With/without activityTrauma

Timing and position bilateral/unilateral relieved with elevationImmobilized

Meds, drugs, diet (birth control)

Exam

Pitting vs non pittingSwelling local and degreeSkin TexturePitting vs non pittingPitting – CHFNon-pitting- lymph blockage that

occurs with tumors

Exam

Pitting vs non pittingPitting – CHFNon-pitting- lymph blockage that

occurs with tumors

Exam

Swelling (B) swelling which spares the

ankles in obese women fat deposition( lipedma)

localized behind the kneebakers cyst (popliteal cyst) or medial gastroc rupture

Exam

SwellingSwelling of tibial crest

Myxedema in hyperthyroid ptsLocalized hard and tender

bone or soft tissue tumorUnilateral swelling in calf

DVT

Exam

Skin TextureDry and scaly skin with

progressive thickening Lymphedema

Diffuse redness and warm skin or red streaks appear on leg Cellulitis

Golden brown skin, hemosideran depositionChronic venous insufficiency

Exam

Skin TextureIndurated orange peel skin.

Lymphatic obstruction Bluish purple discoloration at the medial malleolus

Gastroc tearSkin cool and hypersensitive-

early stage, taut shiny thin skin- late stageRSD

Exam

Considered orthosHoman’s- DVT or venous

insufficiencyBancrofts test- thrombophelebitisTrendelenburgs- venous valve

insufficiencyLowenburg’s sign- thrombosis

Case Study #1 Big Dan

25 year old college studentHeight 5’10” Weight 256lbsChief Complaint: Low back pain and

bilateral leg swellingOnset: insidiously over the past weekNothing makes it better or worse and it

remains constantPain is described as a deep boring

pain rated at a 4 on the QVAS

Big Dan’s Chief Complaint

Pt also complains of slight abdominal pain located primarily in the RUQ

Pt has not received medical treatment for this condition

Big Dan’s History

No MVA’sFractured R fibula from HS football 99Drinks 3-4 sodas per dayHas several adult beverages per

weekendDiet involves fast food 4-5 times/weekNo Hx of smoking or elicit drug useTaking weight loss supplement from

GNC for about 1 year

Big Dan’s Exam Findings

BP 160/88 BilateralHR 110Cardiac: Posterior Tibial and Dorsal

Pedial pulses are weakAscultory findings: No mumors, clicks,

heart rate regular and rhythmic Pulmonic findings: Clear

Big Dan’s Exam Cont’

Abdominal exam: Bowel sounds heard in all four quadrants, Splenic percussion was dull on inhalation

Marked tenderness on light and deep palpation of RUQ and LUQ and smooth edge of the liver palpated as smooth and firm with a blunt edge

Big Dan’s Exam Cont’

Cranial Nerves: WNL, slight yellow tint to sclera

Motor: 5/5 both upper and lowerSensory: NAD for both accurate and

non accurate pathwaysChiro Exam: +Y R shoulder, +Z head,

+Y R hip, Bilateral internally rotated shoulders

C1 ASRP, C5L, T4L, L4L, R AS

Big Dan’s Differentials Hepatitis: considered d/t palpable finding in

RUQ, yellow sclera, and general college lifestyle

CHF: considered d/t bilateral leg swelling and hypertension

Diabetes: considered b/c systemic metabolic disorders may cause bilateral leg swelling

Cirrhosis: considered d/t yellow sclera, liver palpation, and Hx of alcohol consumption

Liver Failure: Considered d/t yellow sclera, liver and spleen palpation and percussion

Big Dan’s Imaging and Labs

Radiology: Full spine series-unremarkable

CT: reveals liver and spleen enlargement

Labs: Increased Alk Phos, LDH, AST, ALT, and bilirubin

Decreased A:G

Big Dan’s Diagnosis

Acute Liver Failure

While awaiting lab results, with in one day pt acquired substantial systemic jaundice and went directly to ER via EMS were diagnosis was made

The only perceivable contributor was the high doses of the weight loss supplement

Mechanism

Once hepatocytes are damaged, the liver becomes non functional resulting in a decrease of albumin production. This decrease production has a dramatic effect on oncotic pressure in the capillary beds. The jaundice is produced as the bile products are not processed by the liver. Portal hypertension results in splenomegaly and lower leg swelling

Big Dan

Big Dan’s Surgery

Case #2 Mary Jane

37 year old Female5’3” 190lbsWorks in retailChief complaint: Pain in left calf that is

worse when walking or standing for long periods of time. She also says that her left calf feels tight and appears to be slightly larger than the right.

Mary Jane’s Complaint Cont’

Onset: Pain began after getting home from a family vacation in Sydney about 3 days ago

There has been no recent traumaSeverity: 4/10Provocative: prolonged standingPalliative: restNo previous treatment

Mary Jane’s History

Cholecycectomy and appendectomy 99

MVA: rear-ended @ 35 mph in 87Social Hx: 3 cups of coffee per day,1-3

glasses of wine per day, 20 pack years smoker

Meds: Ibuprofen for pain, BCP for 12 years

Mary Jane’s Exam

BP: 140/82 HR:90 PERRLAPulmonary: wheezing on exhalationAbdomen: NADCN: NADMotor: C5=4/5 all else WNLSensory: Paresthesia in L5/S1

dermatomes on leftOrthos: Hip, knee, ankle (-),

Homans (+)

Mary Jane’s Workup

Blood work: WNL

Radiology: Hip, knee, ankle series-unremarkable

Next step?

Mary Jane’s Workup Cont’

Next step should include referral for Doppler ultrasound

Doppler US is slowly replacing the gold standard of ascending contrast venography

Also include D-dimer- global indicator coagulation activation and fibrinolysis, <250 ng/mL= low risk for recurrence of venous thrombosis

Mary Jane’s Differentials DVT: Ruled in with hx of smoking, bcp, and long term

immobilization, confirmed with Doppler US Lipedma: Pt complains of LLS and is over weight,

R/O: typically bilateral Primary varicosities: Pt complains of dull achy pain in lower

extremity with associated swelling, overweightR/O: via inspection, pain is typically on medial aspect

of leg because the Great Saphenous vein is usually compromised

Venous insufficiency: Pt complains of LLS with dull achy pain that is worse with prolonged standing

R/O: trendelenbergs test Thrombophlebitis: Inflammation of a vein + thrombosis,

common with immobilization, bcp, smoking,Still a possible dx: more common than DVT

and some sources show that a (+) Homans is indicative of thrombophlebitis, less likely if superficial veins are competent

Case #3 Betty Chase

63 year old female 5’4” 158 lbs Chief Complaint: Bilateral leg swelling and

shortness of breath with occasional coughing up of sputum. Pt also has mid back pain located between her scapulas

Onset: insidious over the past year Timing: mostly constant, but symptoms are

made worse upon exertion or when lying down

Previous Dx: Hypertension (10 years ago)

Betty’s HistoryPast History:

MI in 1998Appendectomy in 19892 MVAs-minor no tx

Social History: 4 cups of coffee per day1-2 packs per day for 25 years

Occasional drinkerMeds: 9 different medications per day

Betty’s Exam

BP: 172/92 (controlled?) HR:98Temp:99.2

Eyes: AV nicking and soft exudates

Cardiovascular: -jugular venous distention -increased heart rate -ventricular gallop -skin is pale

Betty’s Exam Cont’

Pulmonary: Crackles and wheezes are present

Abdomen: Tender to palpate the RUQ, and LUQ

-Bowel sounds heard in all 4-No bruits ascultated

Inspection and Palpation of lower extremities reveals bilateral pitting edema

Betty’s WorkupRadiology: Chest x-ray

-Cardiomegaly-Pleural effusion-Blunting of costophrenic angles

Next step?CT

Blood: Elevated creatinine and BNPUA: WNL, urine is very concentrated

Betty’s Differentials

CHF: Considered d/t bilateral leg swelling, cardiac exam, long standing hypertension

R/I: with chest x-ray & CT and elevated BNP Liver Failure: Considered d/t bilateral leg swelling

R/O: Liver enzymes not elevated Nephrotic syndrome: Considered d/t bilateral leg swelling,

high blood pressure, and concentrated urineR/O: serum albumin was WNL, no proteinuria

COPD: Considered d/t pt hx of smoking, cough, sputum, and wheezing

R/O: as main concern d/t bilateral leg swelling, still a possibility if pt continues her current lifestyle

Pericardial disease: Considered d/t edema, cough, SOB, and low grade fever

R/O: CT did not show evidence of pericardial fibrosis or thickening

Lower Leg Swelling

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