Buerger’s disease


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Buerger’s disease

  2. 2. HISTORY <ul><li>USUAL CHIEF COMPLAINTS ARE </li></ul><ul><li>Pain in right / left lower limb – intermittent claudication, rest pain </li></ul><ul><li>Ulceration </li></ul><ul><li>Black discoloration of toes / foot </li></ul>
  3. 3. HISTORY OF PRESENT ILLNESS <ul><li>PAIN </li></ul><ul><li>Site, character, radiation of pain </li></ul><ul><li>Enquire whether patient has history of intermittent claudication or not </li></ul><ul><li>Site of pain – foot, calf or thigh </li></ul><ul><li>Whether pain appears on walking, if so after walking for how long? </li></ul>
  4. 4. CONTD <ul><li>Mention the distance he can walk before the pain starts (Claudication distance) </li></ul><ul><li>What happens to pain if he continues walking </li></ul><ul><li>Does it compel him to take rest or the pain disappears on walking or the patient can continue walking inspite of pain </li></ul>
  5. 5. CONTD <ul><li>Progress of claudication- Is the claudication distance same from the onset or the claudication distance has reduced? </li></ul><ul><li>Enquire whether patient has rest pain or not. If rest pain is present – site of rest pain in the toes / foot / calf / over the ulcer or gangrenous area </li></ul>
  6. 6. CONTD <ul><li>How does the patient get relief? </li></ul><ul><li>Often patient has some relief by keeping the leg hanging below the bed or by application of warmth </li></ul>
  7. 7. DETAILS ABOUT THE ULCERATION OR THE GANGRENE <ul><li>Onset, any history of trauma, progress of ulceration or the gangrene </li></ul><ul><li>Any pain over the site </li></ul>
  8. 8. ANY HISTORY OF SUPERFICIAL PHLEBITIS <ul><li>Ask whether patient has any pain, swelling or discolouration along the course of superficial veins </li></ul>
  9. 9. ANY HISTORY OF RAYNAUD’S PHENOMENON <ul><li>Ask whether patient has pain, pallor on exposure to cold and afterwards any bluish discolouration of toes or fingers and whether this is followed by dusky red congestion in the feet and hand and any burning pain </li></ul><ul><li>Enquire whether gangrene at finger tips has been preceded by such attack or not </li></ul>
  10. 10. CONTD <ul><li>Enquire about chest pain and its relation with exercise (Suggesting anginal pain) </li></ul><ul><li>Any history of blackout or loss of consciousness (Suggesting any cerebrovascular disease) </li></ul><ul><li>Any history of abdominal pain or other gastrointestinal symptoms </li></ul>
  11. 11. CONTD <ul><li>Any tingling, numbness or weakness of any of the limbs </li></ul><ul><li>Any history of impotence (may suggest aortoiliac disease) </li></ul><ul><li>Bladder and bowel habits </li></ul>
  12. 12. PAST HISTORY <ul><li>Similar illness in any other limb in the past </li></ul><ul><li>Any history of hypertension or other cardiac disease </li></ul><ul><li>Any history of diabetes or collagen disease </li></ul>
  13. 13. PERSONAL HISTORY <ul><li>Detail history of smoking </li></ul><ul><li>When did he start smoking </li></ul><ul><li>How many cigarette / bidi per day </li></ul><ul><li>Is he still continuing smoking or given up If so when? Any relief after that </li></ul>
  14. 14. FAMILY HISTORY <ul><li>Enquire about peripheral vascular disease particularly atherosclerotic disease in the family </li></ul>
  15. 15. TREATMENT HISTORY <ul><li>Any drug treatment </li></ul><ul><li>Any surgical treatment already done </li></ul><ul><li>HISTORY OF ALLERGY </li></ul>
  16. 16. PHYSICAL EXAMINATION <ul><li>General Survey </li></ul><ul><li>Decubitus Patient may be comfortable with the affected legs hanging below the level of the bed </li></ul><ul><li>Pulse r ate, rhythm, character of pulse, condition of arterial wall </li></ul><ul><li>Details of peripheral pulses is to be described under local examination </li></ul>
  17. 17. LOCAL EXAMINATION <ul><li>EXAMINATION OF BOTH LOWER LIMBS </li></ul><ul><li>Inspection Keep both lower limbs side by side </li></ul><ul><li>Attitude of limb </li></ul><ul><li>Any deformity – loss of toes or any other deformity </li></ul><ul><li>Any muscle wasting in thigh, calf or foot </li></ul>
  18. 18. <ul><li>CONDITION OF VEINS </li></ul><ul><li>Normally filled veins are seen in both lower limbs </li></ul><ul><li>Any discolouration along the veins </li></ul><ul><li>Look for any guttering of veins (In ischaemic limb the veins will be collapsed and pale blue gutters are seen along the course of the veins) </li></ul><ul><li>This may appear with the patient supine or while elevating the leg during Buerger’s test </li></ul>
  19. 19. WHAT DO YOU MEAN BY GUTTERING OF VEINS <ul><li>In a normal person the veins on the legs are full </li></ul><ul><li>When the legs are raised above the level of the heart the veins collapse </li></ul><ul><li>However if the circulation is normal the veins do not empty completely </li></ul><ul><li>In ischaemic limbs the veins may remain collapsed </li></ul>
  20. 20. CONTD <ul><li>In case of severe ischaemia on raising the limb to 10 to 15 degree pale blue gutters may appear along the course of veins </li></ul><ul><li>This is called guttering of veins </li></ul>
  21. 21. <ul><li>LOOK FOR SIGNS OF PEIPHERAL ISCHAEMIA </li></ul><ul><li>Condition of skin – Thin shiny skin </li></ul><ul><li>Loss of subcutaneous fat </li></ul><ul><li>Loss or diminished hair over toes, dorsum of foot </li></ul><ul><li>Changes in nail – whether nails are brittle and there are transverse ridges on the nail </li></ul>
  22. 22. <ul><li>GANGRENE </li></ul><ul><li>Site and extent of gangrene </li></ul><ul><li>Type (dry or moist) </li></ul><ul><li>Colour of the gangrenous area </li></ul>
  23. 23. CONTD <ul><li>Line of demarcation- note the level and depth of demarcation – whether skin, muscle or bone deep </li></ul><ul><li>Observe the limb above the gangerenous area – whether pale, congested or oedematous </li></ul><ul><li>Look at the pressure areas – heel, malleoli, ball of the foot, tip of the toes </li></ul>
  24. 24. PALPATION <ul><li>SKIN TEMPERATURE – start palpating from the foot and find at what level temperature becomes normal in comparison to the normal side </li></ul><ul><li>GANGRENE </li></ul><ul><li>Site </li></ul><ul><li>Sensation </li></ul><ul><li>Tenderness </li></ul><ul><li>Any local crepitus </li></ul>
  25. 25. CONTD <ul><li>Limb adjacent to gangrenous areas </li></ul><ul><li>Tenderness </li></ul><ul><li>Pitting oedema </li></ul>
  26. 26. SPECIAL TESTS FOR ASSESSMENT OF CIRCULATORY INSUFFICIENCY <ul><li>BUERGER’S TEST (Vascular angle) In a normal person the leg can be kept at 90 degree angle without appearance of any pallor </li></ul><ul><li>Appearance of pallor at 20 degree indicates severe ischaemia </li></ul>
  27. 27. HOW WILL YOU ASSESS BUERGER’S ANGLE OF CIRCULATORY INSUFFICIENCY VASCULAR ANGLE <ul><li>Keeping the patient supine in the bed, raise leg gradually and keep at 20 degree angle to the bed for 2 minutes and look for pallor or any discomfort – pain </li></ul><ul><li>If no pallor – raise limb to 30 degree / 45 degree / 60 degree / 90 degree and look for pallor </li></ul><ul><li>Mention at what level pallor appears </li></ul>
  28. 28. CONTD <ul><li>The angle at which pallor appears is called Buerger’s angle of circulatory insufficiency </li></ul><ul><li>In a normal person the leg can be kept at 90 degree angle without appearance of any pallor </li></ul><ul><li>Appearance of pallor at 20 degree indicates severe ischaemia </li></ul>
  29. 29. HOW WILL YOU ASSESS CAPILLARY FILLING TIME <ul><li>After estimating the vascular angle by noting the level at which pallor appears </li></ul><ul><li>Patient is asked to sit up and hang his leg below the bed </li></ul><ul><li>A normal leg will maintain the pink colour </li></ul><ul><li>An ischaemic leg will show change of colour from pallor to pink and red purple colour </li></ul>
  30. 30. HOW WILL YOU TEST FOR CAPILLARY REFILLING <ul><li>Press the nail bed or the pulp of the tip of the finger for two seconds- and then release </li></ul><ul><li>Look for the rapidity of capillary refilling </li></ul><ul><li>In normal person there is quick capillary refilling </li></ul><ul><li>In severe ischaemia capillary refilling may be delayed </li></ul>
  31. 31. HOW WILL YOU TEST FOR VENOUS REFILLING <ul><li>Empty a segment of vein by milking with two index fingers and the distal finger is released </li></ul><ul><li>Note the time of venous refilling </li></ul>
  32. 32. HOW WILL YOU DO CROSSED LEG TEST OR FUCHSIG’S TEST <ul><li>Method – Patient sits on a chair with the legs crossed </li></ul><ul><li>One knee resting on the other – divert attention – look for oscillatory movement of upper leg. </li></ul><ul><li>If oscillatory movement is seen – then popliteal pulse is present </li></ul><ul><li>If oscillatory movement is absent – then popliteal pulse is absent </li></ul>
  33. 33. WHAT IS REACTIVE HYPERAEMIA TEST <ul><li>Inflate the sphygmomanometer cuff around the limb and inflate the cuff to about 250 mmHg and keep for 5 minutes </li></ul><ul><li>A pallor will appear release the pressure in the cuff </li></ul><ul><li>Record the time interval between the release of cuff and appearance of red flush in the skin </li></ul>
  34. 34. CONTD <ul><li>In presence of normal circulation the red flush appear within 1-2 seconds </li></ul><ul><li>In a severly ischaemic limb the red flush may not appear at all </li></ul><ul><li>This is called reactive hyperaemia test </li></ul>
  35. 35. MOVEMENTS OF JOINTS ADJACENT TO GANGRENOUS AREA <ul><li>Movement of interphalangeal joint </li></ul><ul><li>Midtarsal joint movement </li></ul><ul><li>Movement of ankle joint </li></ul><ul><li>Movement of knee joint </li></ul>
  36. 36. EXAMINATION FOR NERVE LESION IN LOWER LIMBS <ul><li>Motor system of lower limbs </li></ul><ul><li>Tone </li></ul><ul><li>Power of ankle dorsiflexor and plantar flexor </li></ul><ul><li>Power of knee flexor and extensor </li></ul><ul><li>Power of hip flexor / extensor / abductor / adductors </li></ul>
  37. 37. SENSORY SYSTEM IN LOWER LIMBS <ul><li>Crude touch and fine touch </li></ul><ul><li>Pain sensation tested by pin prick </li></ul><ul><li>Temperature sensation </li></ul><ul><li>REFLEXES Ankle jerk / knee jerk </li></ul><ul><li>Plantar response </li></ul>
  38. 38. EXAMINATION OF INGUINAL LYMPH NODES <ul><li>If palpable, number, size, surface, consistency and mobility </li></ul><ul><li>PALPATION OF PERIPHERAL PULSES </li></ul><ul><li>++ normal </li></ul><ul><li>+ palpable but feeble </li></ul><ul><li>- not palpable </li></ul>
  39. 39. <ul><li>Arteria dorsalis pedis </li></ul><ul><li>Anterior tibial </li></ul><ul><li>Posterior tibial </li></ul><ul><li>Popliteal </li></ul><ul><li>Femoral </li></ul><ul><li>Radial </li></ul><ul><li>Ulnar </li></ul><ul><li>Brachial </li></ul><ul><li>Subclavin </li></ul><ul><li>Carotid </li></ul><ul><li>Superficial Temporal </li></ul>
  40. 40. CONTD <ul><li>Condition of arterial wall </li></ul><ul><li>Palpate along the vessel for any tenderness </li></ul><ul><li>Auscultation along major arteries </li></ul><ul><li>Listen for any bruit along the arteries </li></ul><ul><li>To listen to the bruit over an artery use the bell of the stethoscope and do not press firmly over the artery </li></ul>
  41. 41. GENERAL EXAMINATION <ul><li>Examination of abdomen </li></ul><ul><li>Examination of cardiovascular system </li></ul><ul><li>Examination of respiratory system </li></ul><ul><li>Examination of nervous system </li></ul><ul><li>Examination of spine and cranium </li></ul>
  42. 42. WHAT IS THE IMPORTANCE OF BUERGER’S ANGLE <ul><li>The height at which pallor appears indicates the severity of ischaemia </li></ul><ul><li>The height in cm between the level of sternal angle and the level of heel at elevation indicates pressure in mm of Hg in the foot vessels </li></ul>
  43. 43. CONTD <ul><li>The time taken for the appearance of pink colour is called the capillary filling time and this depends upon the degree of arterial obstruction </li></ul><ul><li>A capillary filling time more than 30 seconds suggests severe ischaemia </li></ul><ul><li>Appearance of the bed purple colour in the dependant leg also suggests severe ischaemia </li></ul>
  44. 44. WHERE DO YOU PALPATE THE NORMAL PERIPHERAL PULSES <ul><li>ARTERIA DORSALIS PEDIS PULSE </li></ul><ul><li>This is palpated on the dorsum of the foot lateral to the tendon of extensor hallucis longus at the proximal first intermetatarsus space from a point midway between the two malleoli </li></ul>
  45. 46. ANTERIOR TIBIAL ARTERY PULSE <ul><li>Anterior tibial pulse is palpated in front of the ankle midway between the two malleoli and just lateral to the extensor hallucis longus tendon </li></ul>
  46. 47. POSTERIOR TIBIAL ARTERY PULSE <ul><li>This is palpated in the medical aspect of the ankle at a point one third of the way between the tip of medical malleolus and the point of the heel and slightly inverting the foot to relax the flexor retinaculum </li></ul>
  47. 48. POPLITEAL PULSE <ul><li>Patient lies supine, flex the knee to 135 degree, heel resting on the bed </li></ul><ul><li>Place the thumbs over the tibial tuberosity </li></ul><ul><li>The popliteal artery is palpated against the tibia in between the medial and lateral condyles of tibia with the fingers of both hands </li></ul><ul><li>Alternatively patient lies prone-knee flexed popliteal pulse may be palpated over the posterior surface of the lower end of femur </li></ul>
  48. 50. FEMORAL PULSE <ul><li>Palpated in the groin below the inguinal ligament at the level of the deep inguinal ring which is midway between the anterior superior iliac spine and the symphysis pubis </li></ul>
  49. 52. RADIAL PULSE <ul><li>Palpated in the forearm just above the wrist joint in between the tendon of flexor carpi radialis and the lateral border of the lower end of the radius </li></ul>
  50. 54. BRACHIAL PULSE <ul><li>Palpated in front of the elbow medial to the tendon of biceps brachii </li></ul>
  51. 56. AXILLARY PULSE <ul><li>Palpated in the lateral wall of the axilla against the shaft of humerus in between the two axillary folds </li></ul>
  52. 57. SUBCLAVIAN PULSE <ul><li>Palpated in the supraclavicular fossa at the level of midclavicular point with the patient lifting the shoulder to relax the deep cervical fascia </li></ul>
  53. 58. CAROTID PULSE <ul><li>Palpated at the medial border of the sternocleidomastoid at the level of the upper border of thyroid cartilage </li></ul>
  54. 59. SUPERFICIAL TEMPORAL PULSE <ul><li>Palpated in front of the tragus over the zygomatic bone </li></ul>
  55. 62. WHAT IS INTERMITTENT CLAUDICATION <ul><li>Intermittent claudication is cramp like pain in the muscle during walking due to inadequate blood supply to the muscle during exercise </li></ul><ul><li>The pain disappears when the patient takes rest and the muscle is relaxed </li></ul>
  56. 63. WHAT ARE THE GRADES OF INTERMITTENT CLAUDICATION <ul><li>BOYD’S CLASSIFICATION </li></ul><ul><li>GRADE I After walking for sometime patient has pain, however the pain disappears when the patient continues to walk </li></ul><ul><li>The pain producing substances are washed off by the adequate collateral supply </li></ul>
  57. 64. CONTD <ul><li>GRADE II Patient has pain after walking but he can continue to walk inspite of slight pain </li></ul><ul><li>GRADE III Patient has pain after walking for sometime with continued walking the pain aggravates and patient has to take rest to get relief from pain </li></ul>
  58. 65. WHAT IS NEUROGENIC CLAUDICATION <ul><li>This is pain in the legs during walking due to some neurological cause and is usually due to nerve compression </li></ul>
  59. 66. HOW WILL YOU DIFFERENTIATE A NEUROGENIC AND VASCULAR CLAUDICATION <ul><li>In vascular claudication patient usually has pain after walking for some distance and patient gets relief by simply taking rest </li></ul><ul><li>In neurogenic claudication patient usually has pain after walking for some distance often after taking few steps </li></ul>
  60. 67. CONTD <ul><li>Patient gets relief after taking rest and on assuming some posture so as to relieve compression of nerve </li></ul><ul><li>All peripheral pulses are palpable </li></ul>
  61. 68. WHAT IS REST PAIN <ul><li>Rest pain is defined as continuous pain throughout day and night in the limb due to severe ischaemia </li></ul><ul><li>The rest pain is due to ischaemia of the nerves and patient has some comfort keeping the foot dependant below the level of bed </li></ul>
  62. 69. WHY REST PAIN IS MORE AT NIGHT <ul><li>Rest pain often awakes the patient up from sleep </li></ul><ul><li>During sleep there is diminution of heart rate and blood pressure may be lower </li></ul><ul><li>This result in further hypoperfusion and may aggravate the ischaemic pain </li></ul>
  63. 70. HOW WILL YOU ASSESS WASTING OF MUSCLES IN THE LIMBS <ul><li>Muscle bulk can be assessed by inspection on comparing the two sides if there is wasting on one side </li></ul><ul><li>If there is bilateral wasting it may be assessed by looking at the thinning of the limbs with bony prominence </li></ul>
  64. 71. CONTD <ul><li>In unilateral wasting it can be further confirmed by measuring the circumference of the two limbs at same level from a bony point say 15 cm below the tibial tuberosity for assessing the calf muscle wasting </li></ul>
  65. 72. HOW WILL YOU GRADE MUSCLE POWER <ul><li>While testing for muscle power it can be graded as </li></ul><ul><li>Grade 0 No muscle contraction. Complete paralysis </li></ul><ul><li>Grade 1 Only flicker of contraction. No movement </li></ul><ul><li>Grade 2 Can move only when the gravity is eliminated </li></ul>
  66. 73. CONTD <ul><li>Grade 3 Can move against gravity but not against resistance </li></ul><ul><li>Grade 4 Can move against some resistance </li></ul><ul><li>Grade 5 Can move against normal resistance. Normal power </li></ul>