Test yourself on some causes of a swollen and painful leg!
Reviewed by Jonathan Loomes-Vrdoljak
Approach to the patient with a swollen painful leg
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Stem 1, question 1 of 3
Shoshanna, a 65 year old female, presents with a swollen and painful right leg to her local urgent treatment centre.
Which of the disease process is being described: "Thrombus formation in a superficial vein and inflammation in the surrounding tissue of that vein"?
Deep vein thrombosis
Question 1 Explanation:
This is a simple match the definition with the term. Both cellulitis and erysipelas are infections of the skin. Trauma can result in thrombus formation as a secondary result. Deep vein thrombosis is also incorrect as the definition in the question clearly states superficial.
Stem 1, question 2 of 4When asked about past medical history Shoshanna explains she is currently being treated with trastuzumab and had a lumpectomy 2 months ago. Given these risk factors, what is the most likely diagnosis for Shoshanna's swollen and painful leg?
Deep vein thrombosis
Ruptured Popliteal Cyst
Question 2 Explanation:
This question tests your understanding of risk factors for deep vein thrombosis (DVT). The stem gives a number of risk factors for deep vein thrombosis, but requires application to know this. Trastuzumab is a monoclonal antibody used to treat breast cancers with an over expression of HER-2, remember that active cancer is a major risk factor for DVT. Another risk factor for DVT includes surgery in the last 3 months, Shoshanna had a lumpectomy 2 months ago. Thus, given the information in the stem the most likely diagnosis is a deep vein thrombosis
Stem 1, question 3 of 4Which of the following is not an examination finding in a deep vein thrombosis?
Localised pain along deep venous system
Prominent superficial veins
Phlegmasia cerulea dolens
Unilateral calf swelling
Question 3 Explanation:
Symmetrical oedema is not usually an examination finding in DVT, usually oedema will be asymmetrical. Phlegmasia cerulea dolens can occur when a DVT is large enough to obstruct both venous and arterial inflow which causes ischaemia, the affected limb will appear blue and painful.
Stem 1, question 4 of 4Shoshanna is started on Dabigatran to treat her deep vein thrombosis. What is the mechanism of dabigatran?
Inhibition of Vitamin K epoxide reductase
Inhibition of factor Xa
Inhibition of thrombin and factor Xa by complexing antithrombin III
Inhibition of thromboxane synthesis
Inhibition of thrombin
Question 4 Explanation:
Dabigatran is a direct thrombin inhibitor. The other answers are the mechanism of warfarin, apixaban/rivaroxaban/edoxaban, heparin and anti platelet drugs respectively.
Stem 2, question 1 of 3
Sven, a 28 year old man, had a motorbike accident and was found to have broken his right tibia and fibula, causing a swollen and painful leg.
The next day Sven complains of increasing pain in his right leg and notices it appears cold and pale. What is the most likely diagnosis?
Deep vein thrombosis
Ruptured popliteal cyst
Question 5 Explanation:
This is when the 5 P's comes in very helpful. Say it with me now "Pain, pulselessness, paraesthesia, pallor and perishingly cold!". Given the recent history of a fracture with the increasing pain, pallor and (perishingly) cold presentation of the limb, compartment syndrome is the only answer choice that fits.
Stem 2, question 2 of 3What is the definition of compartment syndrome?
A pathological condition characterised by elevated interstitial pressure in a closed muscular compartment that results in macrovascular compromise
A pathological condition characterised by reduced extracellular pressure in a closed osteofascial compartment that results in microvascular compromise
A pathological condition characterised by elevated interstitial pressure in a closed osteofascial compartment that results in macrovascular compromise
A pathological condition characterised by elevated interstitial pressure in a closed osteofascial compartment that results in microvascular compromise
A pathological condition characterised by reduced interstitial pressure in a closed osteofascial compartment that results in microvascular compromise
Question 6 Explanation:
This question is a relatively simple direct recall of a definition but all five answer options are worded very similarly to try to stop you from guessing it. Compartment syndrome occurs due to increased interstitial pressure due to intra-compartmental bleeding in a closed space and so results in small vessel compromise. The main arteries travelling through the compartment are at a higher pressure so are typically not occluded until very late stages, if at all. Therefore, loss of distal pulses is a late indicator of compartment syndrome (source: Fracture management by John Keating in Textbook of Orthopaedics, Trauma and Rheumatology accessed via Clinical Key)
Stem 2, question 3 of 3Sven undergoes an emergency fasciotomy to relieve the pressure in the anterior compartment of the leg. What is the function of the anterior compartment of the leg?
Dorsiflexion of the foot and ankle
Eversion of the foot
Plantarflexion of the foot
Plantarflexion and inversion of the foot
Plantarflexion and eversion of the foot.
Question 7 Explanation:
The function of the anterior compartment of the dorsiflexion of the foot and ankle as this requires a smaller group of muscles than the posterior compartment that provides plantarflexion movement.
Stem 3, question 1 of 3
Elsabeth, an 84 year old female, presents to her GP with a hot, swollen and painful left leg that appears to be spreading. It is red, raised and swollen, there is a sharp border between the uninvolved skin. Elsabeth also has lymphoedema, venous insufficiency and healing leg ulcer.
What is the most likely diagnosis?
Deep vein thrombosis
A ruptured popliteal cyst
Question 8 Explanation:
Elsabeth is presenting with signs of cellulitis but more speficically erysipelas. This is a distinct form of superficial cellulitis with notable lymphatic involvement and is raised with a sharp demarcation from uninvolved skin. Erysipelas involves the upper dermis and extends into the superficial cutaneous lymphatics and predominantly affects the skin of the lower limbs. Cellulitis does not usually exhibit such marked swelling but will present with pain and increased warmth of affected skin without such clear and sharp borders. The question stem also highlights risk factors for this condition. DermNet NZ highlights the risk factors for erysipelas: venous disease including leg ulceration and lymphoedema, older age, previous episodes, breaks in the skin barrier, current or prior injury, immune deficiency, nephrotic syndrome and Pregnancy. The stem highlights older age, venous disease and breaks in the skin barrier. DermNet NZ is a very helpful resource for dermatological conditions. Reference: https://dermnetnz.org/topics/erysipelas/
Stem 3, question 2 of 3Elsabeth is diagnosed with erysipelas, which of the following is a common causative organism of this?
Question 9 Explanation:
Beta-haemolytic streptococci and Staphylococcus aureus are the common causative agents of cellulitis and erysipelas. Cryptococcus neoformans is a yeast, toxoplasma gondii is a protozoan. Streptococcus aureus does not exist. Unfortunately with this question it's one that you either know, or you don't!
Stem 3, question 3 of 3Which of the following is most appropriate to start to treat Elsabeth?
Question 10 Explanation:
Flucloxacillin is the first line for cellulitis and erysipelas as these provide cover for methicillin resistance Staphylococcus aureus *remember to consult local antibiotic guidelines for your area*. Ethambutol is used to treat tuberculosis, aciclovir and maraviroc are anti-virals for herpes simplex and HIV respectively. Fluconazole is an anti-fungal agent.
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