EXTREMITY PAIN, LOWER EXTREMITY

Ask the following questions:

1. Is the extremity pain of acute or gradual onset? Acute onset would suggest arterial embolism, deep vein thrombophlebitis, and cellulitis. If there is a history of trauma, it would suggest a fracture, sprain, or torn ligament.
2. Is there limitation of motion of the joints? A positive Patrick's test would indicate hip pathology, including greater trochanter bursitis. A positive McMurray test would indicate a torn meniscus.
3. Are there positive neurologic findings? A positive femoral stretch test would suggest a herniated disk at L2-3 or L3-4, whereas a positive Lasègue's sign would indicate a herniated disk at L4-5 or L5 to S1. Combined motor and sensory deficits may indicate radiculopathy or neuropathy.
4. Is there a positive Homans' sign? This is a very important examination, as one would not want to miss a deep vein thrombophlebitis.
5. Is there diminished or absent peripheral pulses? Diminished or absent pulses would suggest arterial embolism, peripheral arteriosclerosis, or Leriche's syndrome (thrombosis of the terminal aorta).
6. Is there focal tenderness, swelling, or erythema of the extremity? This would suggest cellulitis, superficial thrombophlebitis, osteomyelitis, lymphangitis, and other types of infections. Tenderness without significant swelling or erythema would be suggestive of bursitis or deep vein thrombophlebitis.

DIAGNOSTIC WORKUP

Often bursitis and myofascitis can be diagnosed by the dramatic relief obtained from a lidocaine injection. If there is clear-cut joint pathology, an x-ray of the joints, arthritis profile, and synovial fluid analysis will usually provide a diagnosis. MRI is useful in the diagnosis of a torn meniscus. If a deep-pain thrombophlebitis is suspected, venous Doppler ultrasound, impedance plethysmography, or a contrast venogram may be done. If an arterial embolism or chronic peripheral arterial disease is suspected, femoral angiography can be done. If a herniated disk or other pathology of the lumbar spine is suspected, plain films of the lumbar spine should be obtained. It might be wise at this point also to obtain a CBC, sedimentation rate, and chemistry panel to determine the alkaline phosphatase, calcium, and phosphorus. In older males, tests for acid phosphatase and PSA should be done.

If these tests are unrevealing, it is wise to refer the patient to a neurologic specialist before any more expensive tests are ordered. He will probably order a CT scan of the lumbar spine and may do nerve conduction velocity studies, EMG examinations, or dermatomal SSEP studies as indicated. In difficult neurologic problems, a combined myelography and CT scan is preferred over MRI. Bone scans will help diagnose obscure fractures and osteomyelitis, both of the lumbar spine and the lower extremities.

Book Source Details

• Book Title: Algorithmic Diagnosis of Symptoms and Signs
• Author(s): R. Douglas Collins
• Year of Publication: 2003
• Copyright Details: Algorithmic Diagnosis of Symptoms and Signs, Copyright © 2003 Lippincott Williams & Wilkins.

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More About This Book: Title: Algorithmic Diagnosis of Symptoms and Signs Authors: R. Douglas Collins Publisher: Lippincott Williams & Wilkins Copyright: 2003 ISBN: 0-7817-3805-9

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