Differential diagnosis of lower limb swelling

• Bilateral swelling DK - literally. systemic diseases .
• Unilateral swelling DK - no. deep vein thrombosis or cancer .

Anamnesis

• Emergence of swelling - suddenly (HT), slowly ( cardiac insufficiency );
• soreness ( HVT , Baker's cyst );
• after long-term immobilization (HŽT);
• after trauma (muscle rupture, fracture, compartment syndrome );
• accompanying onema (cardiac/renal insufficiency, liver cirrhosis ), cancer (especially small pelvis), influence of drugs ( BKK , corticoids , NSAIDs ).

Examination

Physical exam

• Reddish hot skin – erysipelas , Deep Vein Thrombosis (DVT);
• compressible edema – cardiac, renal, hepatic edema;
• incompressible swellings ( lymphatic , lipidedema ).

USG examination - 3D Doppler

• Vein patency.

Differential diagnosis

• Vascular etiology;
  • DVT (unilateral, acutely formed, elastic, painful swelling - possibly with hot, tense skin);
  • thrombophlebitis (inflamed subcutaneous vein - a red, painful strip to the touch);
  • varices (one/bilateral compressible swelling, increasing during the day, decreasing with positioning);
  • chronic venous insufficiency /=CVI (unilateral/bilateral swelling, mostly with skin changes and/or leg ulcer );
• neurological etiology (paresis for blood flow stasis for unilateral angioparesis, tendons are not usually affected);
• cardiac etiology (right-sided insuf. – bilateral compressible on the instep and lower leg, characteristically increase after exertion, are smallest in the morning);
• hypoproteinemic swellings (in hepatopathies – cirrhosis, renal – nephrotic syndrome , acute glomerulonephritis , protein loss in exudative enteropathy);
• lipedema (chronic bilateral painless incompressible swelling – most obese women, with skin changes of the orange type, characteristically the insteps and tendons are spared);
• lymphedema (chronic unilateral/bilateral swelling, characteristically affected also the insteps and tendons, the leg has the shape of a post, in extreme cases the development of elephantiasis );
• pharmacologically conditioned (nifedipine, glucocorticoids , vasodilators, NSAIDs, hydralazine, minoxidil,...);
• endocrine etiology (typically bilateral);
  • Basedow's disease (incompressible, pretibial myxedema, pasty skin, bluish-red, coarse pores);
  • hypothyroidism (generalized myxedema, especially in the face and all limbs);
• traumatic etiology (mostly one-sided swelling, history of fracture, untorn meniscus, etc.);
• postoperative (reperfusion swelling after vascular procedures (bypass, removal of vessel obliteration), great pain, the area is hot, often after removal of the great saphenous vein /=VSM);
• compartment syndrome ;
• neoplasia (typically unilateral in tumors – e.g.: tumors in the small pelvis, local swelling in osteosarcoma , Ewing's sarcoma );
• inflammatory etiology ( erysipelas – red, painful swelling, we look for the entrance gate of the infection + we check vaccination against tetanus and possibly revaccinate);
• Baker's cyst (unilateral soft swelling in the popliteal fossa, palpable resistance, USG examination is diagnostic).

Links

References

• GESENHUES, S and R ZIESCHÉ. Vademecum doctor. 1st Czech edition. Prague: Galén, 2006.  ISBN 80-7262-444-X .