Introduction
Wash your hands, introduce yourself, and ask permission (consent) to examine. Ask if the patient has any pain. Obtain full exposure of the limbs you are examining (for the legs, ideally trousers should be removed).
History features:
- Symptoms (aching pain, fatigue, leakage/bleeding, ulcers), impact on life (including activities of daily living, hobbies & work - do they do lots of standing?)
- What patient wants/expects in terms of medical help and outcomes of any treatment!
- Onset of symptoms. In females, any recent pregnancy?
- Family history
- Previous treatments tried
- Associated previous medical history - eg. pelvic cancers, previous deep venous thrombosis, etc.
Inspection
Look for:
- Varicosities: Follow the paths of the two major veins. Long saphenous (ascends in front of the medial malleolus and runs along the medial side of the leg, going behind the medial condyles and along the medial side of the thigh and, passing through the fossa ovalis and ending in the femoral vein at the SFJ). Short saphenous (ascends behind the lateral malleolus and runs laterally, crossing to the middle at the lower part of the popliteal fossa, and ending in the popliteal vein, between the heads of the Gastrocnemius. Also gives off a branch which joins the great saphenous vein)
- Thread veins: Thin thready superficial varicosities.
- Malleolar flare: spider-like venous tortuosities around the malleoli.
- Venous eczema: caused by leakage of irritative venous contents onto skin surface
- Haemosiderin deposits
- Lipodermatosclerosis: indurated areas of brown/red/orange thickened skin caused as a result of fibrosis of subcutaneous fat - palpate for this
- Inverted ?champagne bottle? shape of legs: narrow around ankle, due to chronic venous insufficiency leading to fibrosis
- Oedema (swelling)
- Ulcers & atrophie blanche: (white scar tissue with 'dotted' capillaries)
Clinical Tests and Palpation
Feel for:
NB: Sapheno-femoral junction (SFJ) = 4cm below femoral veins
- Get the patient to cough whilst feeling at the SFJ (follow the vein up along it's path)
- 'Tap test' - tap the vein above (proximally) whilst feeling below with a finger held on the more distal portion of the vein. This allows you to assess for valvular incompetence.
- Feel for phlebitis along the veins.
- Consider palpating for the peripheral pulses (you may want to know if the arterial supply is adequate prior to using compression bandaging).
- Optional: auscultation for bruits and A/V fistulae.
Tourniquet test (Trendelenburg test)
- Lift the leg up to drain veins (while the patient lies on a couch)
- Tie the tourniquet initially at the SFJ. Aim is to see if you can stop the veins re-engorging when the leg is lowered again. If the varicosities re-fill once the leg is lowered (with the tourniquet at the SFJ) then any distal perforators are incompetent.
- The 'Modified test' involves subsequently attaching the tourniquet distally, at varying distances along the leg to try and see where the incompetent perforators are located.
- Other sets of perforators include: Hunterian perforator (mid-thigh), Dodd perforator (approximately 1 hands breadth above knee), Boyd perforator (approximately 1 hands breadth below knee) and Cockett perforators (5, 10 and 15cm above the ankle).
Perthes test:
- Used to detect significant deep venous occlusion or insufficiency.
- Apply the tourniquet just below the SFJ (tight enough to occlude the superficial venous drainage).
- Get patient to stand up and down on toes for few minutes.
- If there is significant deep venous occlusion (or insufficiency), then the patient will experience 'bursting' pain or 'tightness' in the calf (venous claudication). This is due to the inability of blood to be drained out of the leg through the tourniquet-occluded superficial venous system.
- To finish, mention that you would like to examine the abdomen, and to perform a PV (per vaginal) & PR (per rectal) examination. This is to determine if there are any abdominal masses present causing the lower limb venous disease.
Extra notes
Varicose veins definition:
Varicose veins are tortuous, elongated dilated and thickened veins with non-functional and incompetent valves.
Risk factors:
Genetics (family history), female sex (hormonal role), gravitational - hydrostatic forces (lots of standing), hydrostatic muscular compartment force (ie. weakened muscle pump)
Treatments:
- Conservative: lifestyle changes (weight loss, exercise), education (keep leg elevated, skin care, prevent injury) & graded compression stockings - usually Class 2 (<30mmHg) or 3 (<40mmHg) (cannot use with concomittant arterial pathology or will lead to ischaemia), regular debridement and cleaning/dressing of ulcers
- Intermediate: sclerosant therapy
- Surgical: venous 'stripping' and ligatation
Surgical indications:
'PUBE'
Phlebitis
Ulcers
Bleeding
Eczema
