perpheral vascular disease & gangrene examination

EXAMINATION OF PERIPHERAL VASCULARDISEASE AND GANGRENE

BHAGEERATH REDDY P

Out line…

• HISTORY• PHYSICAL EXAMINATION• LOCAL EXAMINATION

o ISPECTIONo PALPATIONo AUSCULTATION

• GENERAL EXAMINATION

Age & sex

Atherosclerosis – disease of old age, men > womenBuerger’s disease – men 20-40 yrs.Raynaud’s disease – young women.Diabetic arteriopathy – middle age.

Limbs affected:

Buerger’s disease & atherosclerotic ischaemia – lower limbsRaynaud’s disease – upper limbs.Bilateral or Unilateral:

• Buerger’s & Raynaud’s – bilateral • Atherosclerotic gangrene – unilateral bilateral• Gangrene due to embolism – unilateral. • Diabetic gangrene – uni or bilateral.

Mode of onset:

• Gangrene due to atherosclerosis, Buerger’s disease and Raynaud’s disease occur spontaneously and gradually.• Embolic gangrene – suddenly with severe pain.

PAIN

INTERMITTENT CLAUDICATION

REST PAIN

•Continuous aching•Cry of dying nerves

INTERMITTENT CLAUDICATION

Accumulation of excessive P-substance

Inadequate blood flow

Muscle pain

Site of pain level of arterial occlusion

In foot - lower tibial or plantar arteriesIn calf - femoro-popliteal jn.In thigh - opening of sup.femoral arteryIn buttock - bifurcation of common iliac - artery or the aorta.

Claudication distance: The patient complains after walking a distance, pain starts.Boyd’s classification:

Grade-I sometimes if the patient continues to walk pain disappears.Grade-II pain continues & patient can still walk with effort.Grade-III pain compels the patient to take rest

EFFECTS OF HEAT AND COLD:

These are attacks repeated till the end patches of sup.ulceration and gangrene appear at the finger tips- LOCAL GANGRENE

Stages in Raynaud’s disease….

Paresthesia – numbness,pins & needles and other types of paresthesia in the skin of the foot. Due to- shunting of blood from skin to muscles.

H/O superficial phlebitis – swelling, redness and minor pain in the affected part.

Involvemet of other arteries.

PHYSICAL EXAMINATION

A. INSPECTION

B. PALPATION

C. AUSCULTATION

LOCAL EXAMINATION

GENERAL EXAMINATION

INSPECTIOINSPECTIONN1. Change in colour2. Signs of ischaemia3. Buerger’s postural test4. Capillary filling time5. Venous refilling.

1. CHANGE IN COLOUR1. CHANGE IN COLOUR

• Marked pallor – sudden arterial obstruction. in embolism or Raynaud’s disease• Congestion and purple blue cyanosed – severe ischaemia and pregangrenous stage

• Thinning of skin• Diminished growth of hair• Loss of subcutaneous fat• Shininess• Trophic changes in nails – brittle & transverse ridges

3. BUERGER’S POSTURAL TEST:3. BUERGER’S POSTURAL TEST:PROCEDURE:The patient lies on his back, and asked to raise his legs one after the other keeping the knees straight.The legs of normal individual remain pink even if they are raised to 90˚.But in case of ischaemic limb elevation to a certain degree will cause marked pallor and the veins will be empty and guttered.Buerger’s angle or Vascular angle.<30˚ - severe ischaemiaIf not pallor – occlusive arterial disease is suspected.

4. CAPILLARY FILLING TIME:4. CAPILLARY FILLING TIME:

• After elevating the legs, the patient is asked to sit up and hang his legs down by the side of the table.• A normal leg will remain pink as it was during elevated position.• But in ischaemic leg will first become pallor when elevated & gradually become pink in horizontal position.• The change of colour takes place slowly and is called CAPILLARY FILLING TIME.

5. VENOUS REFILLING:5. VENOUS REFILLING:

•After keeping the limb elevated for a while if it is then laid flat on the bed, there will be normal refilling of the veins within 5 sec.•But in ischaemic limb it will be delayed.•If a normal limb is raised to about 90˚ there will be gradual collapse or guttering of the veins. •But in ischaemic limb the veins are seen collapsed either in horizontal position or as soon as it is lifted to even 10˚.

IN ESTABLISHED GANGRENE,IN ESTABLISHED GANGRENE,The following are noted…….1.Extent and colour 2. type – dry or wet3.Line of demarcation4.Observe limb above the gangrenous area.

PALPATIOPALPATIONN1. Skin temperature

2. Capillary refilling3. Venous refilling4. Crossing leg test (Fuchsig’s test)5. Cold and warm water test.6. Elevated arms test.7. Allen’s test8. Branham’s Sign9. Costoclavicular compressive

manoeuvre10.Hyperabduction manoeuvre11.Gangrenous area.12.Crepitus13.Palpation of the blood vessels.

1. SKIN TEMPERATURE:1. SKIN TEMPERATURE:

Best felt with back of fingersCompare the 2 limbs, & feel whole of the limb

2. CAPILLARY REFILLING:2. CAPILLARY REFILLING:

3. VENOUS REFILLING:3. VENOUS REFILLING:

the capillary blood flow time is Longer in ischaemic limb.

Poor in ischamic limb and increased in arteriovenous fistula.This is known as HARVEY’S SIGN

4. CROSSED LEG TEST (Fuchsig’s test)4. CROSSED LEG TEST (Fuchsig’s test)

• To detect popliteal pulsation.• The patient is asked to sit with the legs crossed one above the other so that the popliteal fossa of one leg will lie against the knee of other leg.• The crossed leg will show oscillatory movements of the foot which occur synchronously with the pulse of popliteal artery.• If popliteal artery is blocked, this oscillatory movement will be absent.

To provoke arteriospasm in Raynaud’s disease The patient asked to put hand in…..• Ice water – hand becomes white.• Warm water - hand become blue due to cyanotic congestion.

6. ELEVATED ARMS TEST:6. ELEVATED ARMS TEST:Performed when thoracic outlet syndrome is suspected.PROCEDURE:The patient is asked to abduct his shoulders to 90˚ and at the same time upper limbs are externally rotated fully.Now patient is instructed to open and close his hands for a period of 5 min.A normal individual can perform without difficulty.Patient will complain of tingling and numbness in the fingers.

7. ALLEN’S TEST:7. ALLEN’S TEST:To know patency of radial and ulnar arteries.The patient is asked to clench his fist tightly.The surgeon presses on the ulnar and radial arteries at the wrist.Now pressure is removed and colour of the hand is noted.If any artery is blocked the colour remains white, if patent the palm assumes normal colour.

ALLEN’S TEST:

8. BRANHAM’S SIGN:8. BRANHAM’S SIGN:

This is performed when arteriovenous fistula is suspected.A pressure on the artery proximal to the fistula will cause reduction in the size of swelling, disappearance of bruit, fall in PR.

9. Costoclavicular compressive 9. Costoclavicular compressive manoeuvre or test:manoeuvre or test:

Pateint’s radial pulse is felt.The patient throws shoulders backwards & downwards.This will compress the subclavian artery between clavicle and the first rib leading to reduction or disappearance of radial pulse.

10. Hyperabduction manoeuvre

11. Gangrenous area – dry or wet.

12. Crepitus

13. Limb above the gangrenous area

Pectoralis minor syndrome

Most important part of examination of ischaemic limb.Disappearing pulse- sign of unmasking the preliminary stage of arterial occlusion.Expansile arterial pulse – aneurysm.Embolus in artery – firm & tender.

The following arteries are to be examined:

1. Dorsalis pedis artery2. Posterior tibial artery3. Anterior tibial artery4. Popliteal artery5. Femoral artery6. Radial and Ulnar arteries7. Brachial artery8. Subclavian artery9. Common carotid artery10. Superficial temporal artery

DORSALIS PEDIS ARTERY

POSTERIOR TIBIAL ARTERY

POPLITEAL ARTERY

FEMORAL ARTERY

RADIAL AND ULNAR ARTERIES

BRACHIAL ARTERY CAROTID ARTERY

ADSON’S TEST:ADSON’S TEST:+ in the presence of cervical rib and scalenus anticus syndrome due to compression of the subclavian artery.

AUSCULTATIAUSCULTATIONON

Listen along the course of all major arteriesSystolic bruit over an artery – turbulent bloodflow beyond the stenosisSystolic murmor – aneurysm.Continuous machinary murmor – arteriovenous fistulaBlood pressure of both arms are measured.Reactive hyperaemia test – to know severity of arterial ischaemia.

GENERAL GENERAL EXAMINATIONEXAMINATION

1. Atherosclerosis – examined thoroughly to exclude IHD, CVD, HTN, renal artery stenosis etc.

2. In embolic manifestation, the heart is examined for presence of cardiac murmor

3. Diabetes is often accompanied by atherosclerosis.

4. Peptic ulcer is sometimes accompanied with these diseases.

perpheral vascular disease & gangrene examination

Health & Medicine

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