Severe swelling pain in lower extremities

Introduction Swelling severe pain in the lower limbs is a symptom of primary inferior venous valve insufficiency.

Cause

Congenital vein wall weakness, dilatation, venous valve defects, persistent increase in venous pressure, and venous wall and valvular degeneration are the main causes of venous valve insufficiency in the lower extremities. Heavy labor and long standing are prone to venous valve insufficiency of the lower extremities. When the weight is increased, the pressure in the abdominal cavity is increased, the venous return of the lower extremity is blocked, and the standing is persistent, and the lower extremity muscle is less contracted, which affects the venous return. If the vein wall and the valve are congenitally weak, the above factors can be added to cause the venous valve insufficiency of the lower extremity.

an examination

Related inspection

Angiography

[clinical manifestations]

The patient often feels heavy limbs, soreness, and fatigue. Some may be associated with calf muscle spasms. Some patients may have no obvious discomfort. In the affected limb, especially in the anterior medial aspect of the calf, the superficial veins are uplifted, dilated, distorted, and even curled into a mass of venous tumor-like changes, which are prominent when standing. In patients with longer course of disease, the calf, especially the skin of the ankle, often has nutritional changes, pigmentation, scaling, and even eczema.

Generally, there is less swelling of the calf. If it occurs, there are often not only shallow venous valve insufficiency but also deep venous valve insufficiency. Lower extremity swelling is lighter than deep vein syndrome, generally 2 to 3 cm larger than the healthy side circumference, and rarely more than 4 cm.

The varicose veins are complicated by thrombophlebitis, when the varicose veins are painful, showing redness and hard cords and tenderness. Due to hypoxia of the affected limb tissue, fibrosis of the subcutaneous tissue, exudation of blood metabolites, and local resistance are greatly reduced, so that even in the case of minor injuries and infections, it can cause ulceration of the intractable unhealed. According to Hoave, 800 patients with varicose veins treated by him had 10% with venous stasis ulcer. Ulcers are most common above the medial malleolus because of the lowest position and the highest venous pressure when standing upright. There are few soft tissues in this area, and there are often large and large venous veins in the vicinity, and the nutritional disorders are also the most serious. Ulcers are usually single, and a few can occur in a few places.

The bottom of the ulcer is a dark red unhealthy granulation tissue. The surface may have a thin, odorous oozing fluid, pigmentation of the surrounding tissue, edema or hardening, or eczema-like dermatitis. Such as ulcers unhealed, and edge bulge, crater or cauliflower-like, hard, uneven bottom, easy to bleed, secretions bloody stench, with mucus, suggesting that there may be malignant changes, very rare. The varicose vein can cause acute bleeding due to trauma or the like. It often occurs in the foot boots area, and the atrophied skin is as thin as paper. Underneath it can be seen with venous venules that can withstand high pressure, and slight trauma can cause bleeding. In addition, the bottom of the ulcer often has a perforating vein, and it is often caused by trauma.

[Auxiliary inspection]

According to clinical manifestations, some physical examinations and laboratory special examinations are needed, especially for lower extremity venography.

First, the science check

1. Lower limb circumference measurement: Straighten or slightly bend the lower limbs, measure 15cm on the knee and 15cm below the knee. Generally, the lower edge of the humerus (when the calf is measured) and the upper edge of the humerus (when the thigh is measured) are measured. The values of the contralateral and ipsilateral controls were compared before and after surgery.

2. The deep venous patency test of the lower extremities (Perthes test) was used to measure the patency of deep venous return. The method is to block the great saphenous vein in the thigh with a tourniquet, and the paralyzed patient kicks the leg vigorously or continuously for the lower jaw movement. Due to muscle contraction, the superficial venous blood flow should be returned to the deep vein to make the varicose veins collapse. If the deep vein is not smooth or the venous pressure is increased, the degree of varicose veins will not be alleviated or even worsened. Whether the deep venous valve is closed or not, there is no physical examination (refer to the above manual inspection without instrument) to detect the lesion.

3. Large saphenous vein valve and calf penetrating venous valve test (Trendelenburg test) to determine the position of the valve in the saphenous vein and the venous insufficiency. The patient is placed in a supine position, the lower limbs are raised, and the affected limb is massaged upward from the ankle to make the vein empty. The examiner presses the proximal thigh with a tourniquet and then lets the patient stand. When the tourniquet was released, the saphenous vein was rapidly filled, indicating that the great saphenous vein valve was incomplete; the tourniquet was not released and the saphenous saphenous vein was rapidly filled in 30 seconds, indicating that the calf penetrating through the venous valve was incomplete.

Second, the laboratory has no damage inspection

In recent years, Doppler ultrasound blood flow examination, electrical impedance volume map, photoelectric blood flow meter measurement, etc. have been beneficial to the examination of deep venous patency of the lower extremities and deep venous valve function. However, the ascending and descending lower extremity venography is still a visual method for the diagnosis of deep venous patency and venous valve function.

diagnosis

1. Most of them are long-term standing and strong physical labor, or the symptoms of saphenous vein exfoliation have not improved or short-term recurrence.

2. The affected limb is swollen, and there is swelling and severe pain when standing for a long time. Symptoms and signs of simple varicose veins of the lower extremities.

3. Intravenous pressure measurement, directional Doppler ultrasonography is helpful for diagnosis.

4. Venous angiography

1 antegrade angiography: the deep vein trunk is tubularly dilated, losing bamboo-like formation, blurred valve shadow, often accompanied by superficial vein dilatation.

2 retrograde angiography: can determine the valve function: grade I - valve function is sound, calm breathing without contrast agent to the far side; II - mild valve insufficiency, a little contrast agent backflow, no more than the thigh proximal; III, IV - Moderate valve insufficiency, contrast agent reflux, respectively, reached the knee and knee, but there is still a considerable contrast agent to return to the Han; V-level - severe valve insufficiency, most or all of the contrast agent countercurrent, straight to the ankle.

Differential diagnosis

Differential diagnosis of expansive severe pain when the lower limbs are standing for a long time:

1. Lower extremity deep vein thrombosis syndrome: This disease and deep vein thrombosis syndrome have stagnation of venous blood flow in the lower extremities, and the symptoms and signs are very similar, especially in patients with a long history of deep vein thrombosis. The situation has been unclear, and the deep vein thrombosis has been re-opened, which is more confusing. However, there are still many aspects that can be identified.

2, diffuse edema of the lower extremity: diffuse edema of the lower extremity means that the edema starts from the lower extremity and is diffuse.

3. Lower extremity neuropathic pain: According to the pathological mechanism of pain, chronic pain can be classified into nociceptive or inflammatory pain (appropriate response to painful stimuli) and neuropathic (pathological) pain (inappropriate response induced by nervous system damage). The International Association for Pain Research (IASP, 1994) defines neurogenic pain as "pain caused by primary or secondary damage or dysfunction or transient disturbance in the peripheral or central nervous system"; neurological (pathological) The neuropathic pain is deleted from the four words of transitory perturbation; however, there is no significant difference between the two in clinical practice and they can be used interchangeably.

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