- Cellulitis
- Necrotizing Fasciitis
- Deep Vein Thrombosis
- Acute Limb Ischaemia
- Compartment Syndrome
- Bone and Joint Disease
- Neurological Disorders
Make a focused assessment (Table 30.1). Investigation (Table 30.2) and further management are guided by the differential diagnosis.
- Is characterized by painful swelling and erythema of the skin, with fever.
- If cellulitis is the likely diagnosis, having considered the differential diagnosis (Table 95.1), assess the severity of the illness on the basis of the clinical features and comorbidities, and manage the patient accordingly (Tables 95.3 and 95.4, Chapter 95).
- Should be suspected in an ill patient with severe pain and marked local tenderness of the skin. The skin may show blue-black discolouration and blistering.
- If necrotizing fasciitis is possible, give IV fluid, start antibiotic therapy (Table 95.4, Chapter 95) and seek urgent advice from an orthopaedic or plastic surgeon.
- Should be considered in any patient with new-onset limb pain or swelling, especially if there are risk factors for venous thrombosis (Table 56.1). Upper-limb DVT is rare but may be seen in patients with axillary or subclavian venous catheters or cardiac-device leads, cancer or other thrombophilic states, anatomical abnormalities of the thoracic outlet, or may follow strenuous exercise involving the arm.
- See Chapter 56 for further management of DVT.
- Is characterized by pain and paraesthesia, with absent arterial pulses. The skin distal to the occlusion is cool and may be pale or mottled.
- Causes of acute limb ischaemia include acute thrombosis of a limb artery or bypass graft, embolism from the heart or a proximal arterial aneurysm, aortic dissection with involvement of the limb artery and trauma (e.g. arterial puncture or cannulation).
- Findings on neurological examination (sensory loss/muscle weakness) and Doppler assessment of arterial and venous flow stratify the degree of ischaemia and guide further management.
- If acute limb ischaemia is suspected, give heparin 5000 units IV over 5 min IV, followed by an IV infusion (Chapter 103).
- Seek urgent advice from a vascular surgeon.
- Is defined as increased pressure within a myofascial space (most often tibial), resulting in ischaemia.
- Typically follows trauma, particularly fractures, crush injuries and burns, but can also be caused by constricting casts or accidental pressurized intravenous or extravenous infusions.
- May complicate the nephrotic syndrome, rhabdomyolysis, bleeding disorders and limb infection.
- Suspect compartment syndrome if, in a patient at risk, there is pain which appears disproportionate to the injury, or is worse on stretching the muscles within the affected compartment.
- Seek urgent advice from an orthopaedic surgeon. The diagnosis can be confirmed by compartment pressure monitoring. If confirmed, treatment is decompression of the affected compartment by fasciotomy.
- See Chapter 28 for the assessment of acute arthritis.
- If fracture is suspected or must be excluded, arrange plain radiography (in anteroposterior and lateral views). If fracture is still suspected despite non-diagnostic plain films (e.g. unable to weight-bear because of pain), arrange CT or MRI and seek an orthopaedic opinion.
- Pain arising from the long bones of the limbs is uncommon; it may be caused by primary or metastatic tumours, infection or stress fractures, and loosened hip or knee replacements. Arrange plain radiography (in anteroposterior and lateral views) and seek advice from an orthopaedic surgeon.