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These ten questions test your knowledge of the diagnosis, investigation and management of acute and chronic limb ischaemia.

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Limb claudication

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Question 1

Stem 1 - Question 1

A 60 year old patient presents to his GP with worsening pain in his right leg. The pain comes on in his calf when walking. He’s had intermittent pain for some time now but no pain at rest. He smokes 15 cigarettes a day, his BP is 156/90 and his BMI is 34. His most recent blood tests showed an HbA1c of 48. The GP suspects chronic limb ischaemia.

What might you find on examination?
A
Absent pedal pulses
B
AF
C
Distal right leg red
D
Distended saphenous vein
E
Right foot warm to touch
Question 1 Explanation: 
Whenever examining the lower limb ALWAYS check pedal pulses. The patient has chronic limb ischaemia, so there is likely to be atherosclerosis of the arteries of the right lower limb so it may be harder to palpate the pedal pulses. You should assess the capillary refill time as well; however, you will need to lie the patient down and raise his foot above the level of the heart, so you are truly measuring CRT and not venous reperfusion.

Other signs of limb ischaemia are:

  • femoral bruits
  • shiny, hairless skin
  • cold peripheries and skin
  • ulceration of feet

You may find AF in a patient with ischaemic limb pain, but this would more likely be acute than chronic. A distal inflamed right leg might indicate DVT and the dilated saphenous vein may indicate venous insufficiency, rather than an arterial disorder.

Question 2

Stem 1 - Question 2

The GP has the patient remove his shoes and socks, lie down and then raises their leg by 45 degrees. The right foot rapidly goes pale. When the patient sits back up and hangs his foot over the examination table it goes a dusty pink colour. What is the name of this test?
A
Allen’s test
B
Bainbridge reflex
C
Buerger’s test
D
Thomas’ test
E
Thompson’s test
Question 2 Explanation: 
This is Buerger's test and the result showed a positive indication for peripheral artery disease. A normal limb would not go such a dark colour.

Allen's test is used to check for collateral circulation in the hands before doing an ABG. The Bainbridge reflex is a physiological rise in heart rate in a response to increased atrial pressure. Thomas' test examines hip flexion and Thompson's test is also known as the calf squeeze test and checks to see if the achilles tendon has ruptured.

Question 3

Stem 1 - Question 3

Given the patient’s suspected diagnosis, what is the first line investigation of choice?
A
CT angiogram
B
ECG
C
Fasting blood glucose
D
ABPI
E
Lipid profile
Question 3 Explanation: 
The ankle-brachial pressure index is the first line investigation of choice. For each ankle, you take the highest systolic pedal pulse pressure and divide it by the highest systolic brachial pulse pressure. A score of 1-14 is 'normal', but still be suspicious of such a score if the patient is a diabetic.

The CT angiogram may be used to identify the location of any stenosis but is usually avoided for two reasons: patients are likely to have reduced kidney function due to renal artery stenosis so there is an increased risk of kidney damage from the contrast, and there is also a risk of dislodging emboli that then migrate to the feet causing 'trash foot'.

Tne ECG may be indicated if you were worried about heart failure, ischaemic damage to the heart or AF. Note that AF would more likely be associated with acute limb ischaemia. A lipid profile may be used in assessing his cardiovascular risk or monitoring and dietary interventions but has no indication here and we already know he is obese. Fasting blood glucose is of no relevance as we already know he is diabetic based on his HbA1c.

Question 4

Stem 1 - Question 4

What classification scheme is used to grade the severity of the patient’s limb ischaemia?
A
Fontaine
B
Glasgow-Imrie Score
C
Rutherford
D
Starling
E
Modified Well's Score
Question 4 Explanation: 
The Fontaine classification categorises ischaemic limb pain. Our patient would be level 2 - intermittent claudication. Pain at rest/nighttime (3) and necrosis/gangrene (4) are both signs of critical limb ischaemia and would need to be seen urgently by the vascular team.

The Rutherford classification is used to assess tissue viability.

Question 5

Stem 1 - Question 5

Which medication might the patient be started on to reduce the risk of further ischaemia?
A
Clopidogrel
B
Paracetamol
C
Metformin
D
LMWH
E
Bisoprolol
Question 5 Explanation: 
The management of limb ischaemia includes:
  • Modifying risk factors e.g. diabetes, hypertension, obesity...
  • three month supervised exercise programme
  • analgesia
  • aspirin or clopidogrel
They might also be considered by angioplasty, stenting or a bypass graft.
Question 6

Stem 1 - Question 6

Which of the following ulcers described below is the patient most at risk of developing due to his limb ischaemia?
A
Painful, expanding ulcer on the shin with granulomatous base and violet edges
B
A shallow ulcer with slough and granulation tissue in the gaiter region, surrounded by eczematous and brown-stained skin
C
Deep, punched-out ulcer with minimal exudate and granuloma formation, and evidence of necrosis
D
Deep puncture wound in sole of the foot surrounded by insensate skin
E
Red, non-blanching shiny tissue on the back of the heel
Question 6 Explanation: 
Limb iscahemia affects the arteries so he is likely to develop an arterial ulcer caused by arterial insufficiency. Therefore the base of the ulcer may be dry and be slow to heal, or even necrotic. The other options described:
  • A - pyoderma gangrenosum
  • B - venous ulcer
  • D - neuropathic ulcer e.g. secondary to diabetes
  • E - grade 1 pressure ulcer
  • .

    His diabetes puts him at an increased risk of a diabetic foot ulcer (D) but the question was specifically asking about the ulcer that could be causes by his vascular condition.

    Check out some of our other questions about ulcers.

Question 7

Stem 2 - Question 1

A patient is sent to the surgical assessment unit by his GP with suspected critical, acute on chronic limb ischaemia of the left leg.

Which of the following is most likely to be a sign that the distal limb is non-viable?
A
Non-palpable pedal pulses
B
Fixed staining of skin
C
Pain on passive movement
D
Reduced movement
E
Reduced sensation in toes
Question 7 Explanation: 
Remember the Rutherford classification is used to stratify how viable the limb is.
Question 8

Stem 2 - Question 2

Which medication should be given first in the acute setting to help reverse the cause of the critical limb ischaemia?
A
TXA
B
Heparin
C
Clopidogrel
D
Aspirin
E
Alteplase
Question 8 Explanation: 
In a critical setting, heparin is initially given to all patients, even if they are expecting to receive surgery e.g. to insert a stent. Thrombolysis with tPA may be an option for definitive treatment but not initial treatment. Tranexamic acid would not be indicated here. Clopidogrel and aspirin may have a role to play in the future management of the patient, but not initially.

The patient will also need oxygen, analgesia and IV fluids. Analgesia will probably be paracetamol and opiates. Don't forget to prescribe laxatives and anti-emetics alongside the opiate.

Source: Royal College of Emergency Medicine.

Question 9
Where would you palpate the dorsalis pedis pulse?
A
Posterior to medial malleolus
B
Posterior to lateral malleolus
C
Medial edge of the plantar arch
D
Lateral to extensor hallucis longus
E
Lateral to extensor digitorum longus
Question 10
The dorsalis pedis artery is formed from which artery?
A
Fibular artery
B
Posterior tibial artery
C
Anterior tibial artery
D
Popliteal artery
E
Deep plantar artery
Question 10 Explanation: 
The anterior tibial artery passes into the dorsum of the foot where it becomes the dorsalis pedis. This travels down to the first webspace and gives off deep branches into the sole of the foot.
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