This document discusses the examination of chronic limb ischemia. It covers four parts: history taking including complaints like pain, color changes, and tissue loss; inspection of the limb looking at gangrene, ulcers, color, and pulses; palpation of pulses, sensation, gangrenous tissue, and wasting; and special tests including Buerger's test, venous refilling test, and tests for thoracic outlet syndrome like Adson's test and Wright's hyperabduction test. The document provides detailed descriptions of examination findings and procedures for each part of the examination.

1. Examination of chronic limb ischemia
By / Mohamed Fathy Zaidan (MD)
Lecturer of General surgery

2. I. Complains and history
taking
II. Inspection
III. Palpation
IV. Special test

3. l. Complains

4. Complains
• Pain
1- Claudication ( site- time- distance )
2-Rest pain
• Color changes
• Loss of sensation and limb power (paraesthesia –
paralysis)
• Tissue loss
• Other ischemic manifestation ( TIAs- IHD-
Ischemic bowel)

5. ll. Inspection

6. Items of inspection
• Gangrene
• Ulcer
• Color changes
• Skin and nail affection (trophic changes)
• Veins
• Scar for sympathectomy

7. Gangrene
• Press and see how color fade (5
cardinal manifestations)
1) Loss of color
2) Loss of pulsations
3) Loss of sensations
4) Loss warmth
5) Loss of function

8. Types of gangrene
Dry gangrene
• Shrinked , wrinkled ,
mummified
• No odor ,, no discharge
• Line of demarcation
• Line of separation
• Tissue above normal and
healthy
Wet gangrene
• Swallow , edematous
• Bad odor , purulent
discharge,
• No line of……
• Tissue above shows , edema
, redness, hemorrhagic
bullae ,,skip areas
• Crepitus may be present.

9. Types of gangrene
Dry gangrene Wet gangrene

10. Tissue loss (ulcer)
• Unhealed ulcer for 2
weeks + rest pain=??
• Located distally
• Describe it (site- shape-
size- edge- margin-
floor)

11. Color changes

12. Scar

13. III. Palpation

14. Items of palpation
• Pulsations
• Capillary circulation
• Sensation, motor power
• Palpation of gang. Part
• Palpation of an ulcer
• Wasting

15. Pulsations

16. Radial pulse
• One of the brachial
bilocation..
• Felt against….
• Lateral to the ….
• Started….Ended..
• Comment on the
pulse??

17. Dorsalis pedis pulse
• Continuation of ..
• Felt against….
• Lateral to the ….
• Started at …

18. Posterior tibial pulse
• One of the triple
forcation
• Artery of the posterior
compartment
• Passes between
superficial and deep
Ms. Layer
• Started … ended….by
dividing into ..
• Where to feel it??

19. Popliteal pulse
• PA. started at .. As a
continuation of …ended
at …by becoming…
• Felt against…

20. The triple forcation

21. Popliteal pulse

22. Fuchsig’s test

23. Common Femoral pulse
• Started. .. As a
continuation of….
Ended…. By becoming…
• Artery of the extensor
compartment of the
thigh
• Felt at… against….

24. Capillary circulation

25. Wasting

26. IV. Special
tests

27. 1-Buerger’s test
2-Venous refilling test
3-Cold water test
4-Tests for thoracic outlet syndrome
• Elevated arm stress test
• Adson’s test
• Wright's hyperabduction test
5-Allen’s test
6-BRANHAM’S test

28. Buerger’s test
• Patient on his back
• A-Rising the affected limb
cause blanching within 2-3
M.
• B-Lowering the leg below the
below the horizontal plane
leads to cyanotic
congestion
• Bureger’s angle : is the angle
of elevation ay which the
pallor occurs
• Normally no change of color
occur whatever the position of
the limb.

29. Venous refilling test
• In the horizontal plane
the veins of the foot and
the leg are normally filled
• Collapsed veins= poor
circulation
• Elevate the leg to empty
the V. then hang it down
and estimate the V
refilling time
• Normally V. refilled
in 5-10 sec.
• May prolonged to several
Min. in sever ischemia.

30. Cold and warm water test for
Reynold’s phenomena
• Dip the fingers in cold
water : pallor will occur
• Take out of water :
swallon and cyanosed
• After some time : red
and engorged

32. Elevated arm stress test (for TOS)
• In this position, the
patient opens and
closes his hands
repeatedly
• Positive test
reproduces pain,
heaviness or arm
weakness within the
first minute after
beginning

33. ADSON or scalene maneuver
 Radial pulse diminishes
and disappears on
turning chin to same
side.
 Decreases space
between scaleneus
anterior and medius .

34. Wright's hyperabduction test
 Arm hyperabducted
to 180°leads to
diminishing radial
pulse.
 Neurovascular
structures
compressed in
subcoracoid region
by pectoralis minor
tendon, head of
humerus or coracoid
process.

35. Allen’s test

37. BRANHAM’S test
• 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.

38. Thank you