perpheral vascular disease & gangrene examination

EXAMINATION OF
PERIPHERAL VASCULAR
DISEASE AND GANGRENE
BHAGEERATH REDDY P

Out line…
• HISTORY
• PHYSICAL EXAMINATION
• LOCAL EXAMINATION
o ISPECTION
o PALPATION
o AUSCULTATION
• GENERAL EXAMINATION

Age & sex
Atherosclerosis – disease of old age,
men > women
Buerger’s disease – men 20-40 yrs.
Raynaud’s disease – young women.
Diabetic arteriopathy – middle age.

Limbs affected:
Buerger’s disease & atherosclerotic ischaemia –
lower limbs
Raynaud’s disease – upper limbs.
Bilateral or Unilateral:
• Buerger’s & Raynaud’s – bilateral
• Atherosclerotic gangrene – unilateral bilateral
• Gangrene due to embolism – unilateral.
• Diabetic gangrene – uni or bilateral.

Mode of onset:
• Gangrene due to atherosclerosis, Buerger’s disease
and Raynaud’s disease occur spontaneously and
gradually.
• Embolic gangrene – suddenly with severe pain.

PAIN
INTERMITTENT
CLAUDICATION
REST PAIN
•Continuous aching
•Cry of dying nerves

INTERMITTENT
CLAUDICATION
Accumulation of excessive P-substance
Inadequate blood flow
Muscle pain

Site of pain level of arterial occlu
In foot - lower tibial or plantar arteries
In calf - femoro-popliteal jn.
In thigh - opening of sup.femoral artery
In buttock - bifurcation of common iliac -
artery or the aorta.

Claudication distance: The patient complains
after
walking a distance, pain starts.
Boyd’s classification:
Grade-I sometimes if the patient continues to
walk pain disappears.
Grade-II pain continues & patient can still
walk
with effort.
Grade-III pain compels the patient to take rest

EFFECTS OF HEAT AND COLD:
These are attacks repeated till the end patches
of sup.ulceration and gangrene appear at the
finger tips- LOCAL GANGRENE

Stages in Raynaud’s disease….

Paresthesia – numbness,pins & needles and
other types of paresthesia in the skin of the foot.
Due to- shunting of blood from skin to muscles.
H/O superficial phlebitis – swelling, redness and
minor pain in the affected part.
Involvemet of other arteries.

PHYSICAL EXAMINATION
A. INSPECTION
B. PALPATION
C. AUSCULTATIO
N
LOCAL EXAMINATION
GENERAL EXAMINATION

INSPECTIONINSPECTION
1. Change in colour
2. Signs of ischaemia
3. Buerger’s postural test
4. Capillary filling time
5. Venous refilling.

1. CHANGE IN COLOUR1. CHANGE IN COLOUR
• Marked pallor – sudden arterial obstruction.
in embolism or Raynaud’s disease
• Congestion and purple blue cyanosed – severe
ischaemia and pregangrenous stage

• Thinning of skin
• Diminished growth of hair
• Loss of subcutaneous fat
• Shininess
• Trophic changes in nails –
brittle & transverse ridges

3. BUERGER’S POSTURAL TEST:3. BUERGER’S POSTURAL TEST:
PROCEDURE:
The patient lies on his back, and asked
to raise his legs one after the other
keeping the knees straight.
The legs of normal individual remain
pink even if they are raised to 90˚.
But in case of ischaemic limb elevation to
a certain degree will cause marked pallor
and the veins will be empty and
guttered.
Buerger’s angle or Vascular angle.
<30˚ - severe ischaemia
If not pallor – occlusive arterial disease is

4. CAPILLARY FILLING TIME:4. CAPILLARY FILLING TIME:
• After elevating the legs, the patient is asked
to sit up and hang his legs down by the side
of the table.
• A normal leg will remain pink as it was during
elevated position.
• But in ischaemic leg will first become pallor
when elevated & gradually become pink in
horizontal position.
• The change of colour takes place slowly and is
called CAPILLARY FILLING TIME.

5. VENOUS REFILLING:5. VENOUS REFILLING:
•After keeping the limb elevated for a while if
it is then laid flat on the bed, there will be
normal refilling of the veins within 5 sec.
•But in ischaemic limb it will be delayed.
•If a normal limb is raised to about 90˚ there
will be gradual collapse or guttering of the
veins.
•But in ischaemic limb the veins are seen
collapsed either in horizontal position or as
soon as it is lifted to even 10˚.

IN ESTABLISHED GANGRENE,IN ESTABLISHED GANGRENE,
The following are noted…….
1.Extent and colour
2. type – dry or wet
3.Line of demarcation
4.Observe limb above the gangrenous area.

PALPATIONPALPATION
1. Skin temperature
2. Capillary refilling
3. Venous refilling
4. Crossing leg test (Fuchsig’s test)
5. Cold and warm water test.
6. Elevated arms test.
7. Allen’s test
8. Branham’s Sign
9. Costoclavicular compressive manoeuvre
10.Hyperabduction manoeuvre
11.Gangrenous area.
12.Crepitus
13.Palpation of the blood vessels.

1. SKIN TEMPERATURE:1. SKIN TEMPERATURE:
Best felt with back of fingers
Compare the 2 limbs, & feel whole of the limb
2. CAPILLARY REFILLING:2. CAPILLARY REFILLING:
3. VENOUS REFILLING:3. VENOUS REFILLING:
the capillary blood flow time is
Longer in ischaemic limb.
Poor in ischamic limb and increased
in arteriovenous fistula.
This is known as HARVEY’S SIGN

CROSSED LEG TEST (Fuchsig’s testCROSSED LEG TEST (Fuchsig’s test
• To detect popliteal pulsation.
• The patient is asked to sit with the legs
crossed one above the other so that the
popliteal fossa of one leg will lie against
the knee of other leg.
• The crossed leg will show oscillatory
movements of the foot which occur
synchronously with the pulse of popliteal
artery.
• If popliteal artery is blocked, this
oscillatory movement will be absent.

To provoke arteriospasm in Raynaud’s disease
The patient asked to put hand in…..
• Ice water – hand becomes white.
• Warm water - hand become blue
due to cyanotic congestion.

6. ELEVATED ARMS TEST:6. ELEVATED ARMS TEST:
Performed when thoracic outlet syndrome is
suspected.
PROCEDURE:The patient is asked
to abduct his shoulders to 90˚
and at the same time upper limbs
are externally rotated fully.
Now patient is instructed to open
and close his hands for a period
of 5 min.
A normal individual can perform without difficulty.
Patient will complain of tingling and numbness in
the fingers.

7. ALLEN’S TEST:7. ALLEN’S TEST:
To know patency of radial and ulnar arteries.
The patient is asked to clench his fist tightly.
The surgeon presses on the ulnar and radial
arteries at the wrist.
Now pressure is removed and colour of the
hand is noted.
If any artery is blocked the colour remains white,
if patent the palm assumes normal colour.

8. BRANHAM’S SIGN:8. BRANHAM’S SIGN:
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.

9. Costoclavicular compressive9. Costoclavicular compressive
manoeuvre or test:manoeuvre or test:
Pateint’s radial pulse is felt.
The patient throws shoulders backwards &
downwards.
This will compress the subclavian artery between
clavicle and the first rib leading to reduction or
disappearance of radial pulse.

10. Hyperabduction manoeuvre
11. Gangrenous area – dry or wet.
12. Crepitus
13. Limb above the gangrenous
area
Pectoralis minor syndrome

Most important part of examination of ischaemic
limb.
Disappearing pulse- sign of unmasking the
preliminary stage of arterial occlusion.
Expansile arterial pulse – aneurysm.
Embolus in artery – firm & tender.

The following arteries are to be examined:
1. Dorsalis pedis artery
2. Posterior tibial artery
3. Anterior tibial artery
4. Popliteal artery
5. Femoral artery
6. Radial and Ulnar arteries
7. Brachial artery
8. Subclavian artery
9. Common carotid artery
10. Superficial temporal artery

POSTERIOR TIBIAL ARTERY

RADIAL AND ULNAR ARTERIES

BRACHIAL ARTERY CAROTID ARTERY

ADSON’S TEST:ADSON’S TEST:
+ in the presence of cervical rib and scalenus
anticus syndrome due to compression of the
subclavian artery.

AUSCULTATIONAUSCULTATION
Listen along the course of all major arteries
Systolic bruit over an artery – turbulent bloodflow
beyond the stenosis
Systolic murmor – aneurysm.
Continuous machinary murmor – arteriovenous
fistula
Blood pressure of both arms are measured.
Reactive hyperaemia test – to know severity of
arterial ischaemia.

GENERAL EXAMINATIONGENERAL EXAMINATION
1. Atherosclerosis – examined thoroughly to
exclude IHD, CVD, HTN, renal artery stenosis etc.
2. In embolic manifestation, the heart is examined
for presence of cardiac murmor
3. Diabetes is often accompanied by
atherosclerosis.
4. Peptic ulcer is sometimes accompanied with
these diseases.

perpheral vascular disease & gangrene examination

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