Lower Limb Swelling - Dr Efanga

7/27/2019 Lower Limb Swelling - Dr Efanga

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DEPARTMENTALSEMINAR

BY

DR.EFANGA,S.A.S


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QUESTION

DISCUSS THE DIFFERENTIALDIAGNOSIS AND POSSIBLERADIOLOGICAL FINDINGS INA 40YR OLD WOMAN WHOPRESENTS WITH ACUTE

SWELLING OF THE ENTIRELOWER LIMB


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OUTLINE-INTRODUCTION-DIFFERENTIALS

-CLINICO-PATHOLOGICAL FEATURES

-COMPLICATIONS

-IMAGING MODALITIES

-MERITS & DEMERITS OF MODALITIES-RADIOLOGICAL FEATURES

-INTERVENTION


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INTRODUCTION

The lower limb is the region of the bodythat extends from the hip down to the feet.

The emphasis is thus on the causes of

acute swellings(swellings of rapid onset) thatinvolve a significant aspect of the lower limb

in a 40YR old FEMALE.These causes may be

from infections/inflammations,vascularlesions,and Lymphoedema.


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DIFFERENTIALS

1.SOFT TISSUEINFECTIONS/INFLAMMATIONS

-PYOMYOSITIS-CELLULITIS

-NECROTIZING FASCITIS

-DERMATOMYOSITIS

-RHABDOMYOLYSIS


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2.VASCULAR LESION

-DEEP VEIN THROMBOSIS

-WET GANGRENE

-ACUTE MUSCLE DENERVA-

TION

3.LYMPHOEDEMA


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CLINICO-

PATHOLOGICAL

FEATURES


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PYOMYOSITIS

This is the inflammationof a muscle as a result of a bacterial or fungal

Infection.It may culminate to the formation of

abscess,carbuncles,or infected sinuses that lie

deep in the muscle.It is common in tropical

countries.Staphylococcus aureus is the mostImplicated cause.


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COMPLICATIONS INCLUDE

-OSTEOMYELITIS

-ABSCESS

-INFECTED SINUSES


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CELLULITIS

It is the infection of the deep dermis of the skincommonly caused by b-hemolytic streptococci.

It is most common in the lower limbs.

COMPLICATIONS- LYMPHANGITIS

- LYMPHADENITIS


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NECROTIZING FASCITIS

Bacterial infection of the layer of fascia beneaththe skin due to polymicrobial infection with a

variety of gm +,gm -,aerobic & anaerobic orgs.

There is tissue necrosis and toxin production

with large areas of destroyed & devitalized mu-

scle & soft tissue.It occurs following minor cuts like insect

bite,and commonly seen in diabetics,alcohol/

h ld l hi hl l bl


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The elderly are highly vulnerable.

Presentations include;

-Indolent(1-21 days) before diagnosis

-fever

-drowsiness

-diarrhoea-vomitting

-crepitus(50%)

-discolouration of the skin


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DERMATOMYOSITISIt is an autoimmune inflammatory disorder of the

Skin,subcutaneous tissues and striated mucles. The

Inflammatory process is commonly non-suppurative.

Associated with it is a bluish-red skin erup-tion which occurs on the face,scalp,shoulders,and

Knuckles .In the absence of this rash it is called POL-

YMYOSITIS.


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It is more common in middle aged females(40-

60yrs) but a severe form is seen in children(5-

15yrs).It is associated with malignancies e.g

Carcinoma of the breast,bronchus,stomach,&

Ovary.

Presentations include;

-muscle weakness & aches(due to active inflam-

mation,necrosis,muscle atrophy with fatty rep-

lacement)

1

st

symptom in 80%

l d f


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-low grade fever

-skin erythema,Heliotrope rash(dusky eryrhema

of the eyelids) with peri-orbital oedema.Gottron sign=scaly eythematous papules at

the knuckles,major joints,and upper body.

-elevated muscle enzymes-myositis specific auto-antibodies(anti-jo-1)

COMPLICATIONS;Increased incidence of

malignant neoplasms of the breast,prostate,

lungs,ovary,GI tract,and kidney.


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RHABDOMYOLYSISIt is an acute fulminant potentially fatal disease

of skeletal muscle that entails destruction of

muscles with loss of integrity of its cell membr-

ane via infarction.

Causes include;trauma,severe

exercise,ischemia,burn,toxin,iv heparin thera-

py,viral infection,autoimmune inflammation.


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DEEP VEIN THROMBOSISThis condition is associated with venous obstr-

uction as a result of the sluggish flow of blood

plus the changes in the clotting factors in the

blood that increases the tendency to thrombusformation.There is no preceeding inflammation

of the venous wall.It is most common within the

Deep veins of the calf (posterior surface of the lowerLeg)

/


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The causes/risk factors are as follows;

-Patients on medications e.g,birth control pills,

estrogen replacement therapy,tamoxifen,dia-betes,

-Decreased cardiac function;congestive cardiac

failure,myocardial infarction

-Female related;pregnancy,post partum,large

fibroid,-Trauma & Surgery to the pelvis & lower limbs

-prolonged immobilization

A >40


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-Age>40yrs

-varicose veins

-Polycythemia

-Malignancy

-Smoking

-Patients with blood group A > blood group O

Presentation include;

-swelling(measurement of circumference)

-warmth

-Discolouration of the skin

i i h ff d i i


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-Deep crampy pain in the affected extremity,worse in

the erect position and improves with walking.

-Homans sign- Calf pain with dorsal flexion of the foot

-Payr`s sisgn- Pain on compressing the sole of a foot

COMPLICATIONS-PULMONARY EMBOLISM

-PHLEGMASIA ALBA DOLENS(severely impaired

venous drainage resulting in gangrene)-POST-PHLEBITIC SYNDROME(recanalization to a small

lumen,focal wall changes) due to incompetent

valves.


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WET GANGRENEThis is the death and putrefactive decay of part of

the body due to cessation of blood supply coexis-

ting with an infection by gas forming bacterium

e.g,clostridium perfringens.Diabetics are particul-

arly prone to the infection.


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ACUTE MUSCLE DENERVATION

The loss of nerve supply to a muscle is associat-

ed with atrophy however in most cases fatty infi-

ltration of muscle and oedema occur causing the

Swelling of the affected limb.The cause of this

Denervation may be from stroke.


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LYMPHOEDEMALymphoedema is categorized as primary and

second-ary.The primary type is due to Aplasia,hypoplasia or hyperplasia and is associated

with syndromes liketurner`s,klinefelter`s,noonan`s.It has 3subtypes;congenital Lyphoedema,whichappears shortly after birth,lyphoedemapraecox,which appears atpuberty,lymphoedema tarda which ussuallybegins after 35yrs.

d l h d


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Secondary lymphoedema is an

acquired condition resulting from

obstruction to a previously normallymphatic channels by

metastasis,parasites(FILARIALWORMS),tuberculosis.

Lymphoedema of the lower limbs that

involve the foot progresses

upwards,making the entire limb

oedematous.


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IMAGING MODALITIES1.PLAIN RADIOGRAPHS

-AP,LAT VIEWS OF THE AFFECTED LOWER

LIMB,CXR

2.ULTRASOUND SCAN

-B-MODE,COLOUR DOPPLER,DUPLEX DOPP-LER

3.ANGIOGRAPHY

4.VENOGRAPHY5.LYMPHOGRAPHY


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6.CT SCAN + CONTRAST ENHANCEMENT

7.MRI

-SE(T1 & T2 WEIGHTED)

-GRADIENT RECALLED ACQUISITION IN

STEADY STATE(GRASS)8.RADIONUCLIDE IMAGING

-99mTC-IN VITRO LABELLED PLATELETS

-99mTC-NANOCOLLOIDS


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ULTRASOUND SCANMERITS

1.Non invasive & convenient especially when

the patient is uncomfortable

2.It is cheap and readily available3.Non-ionizing

4.Ability to demonstrate and diferentiate soft

tissues(muscles,tendons,subcutaneous

layer,skin)

5 D i t f th l t


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5.Dynamic assessment of the vascular anatomy

and physiology using B-mode and Duplex

doppler6.Used for interventional procedures such as

drainage and image guided biopsy.

7.Can be used for staging of soft tissue tumour


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DRAW-BACKS1.Marked operator dependence

2.Large and obese individuals coupled with intra

abdominal gas may result in sub-optimal

images3Associated bony lesions can not be demonstr-

ed


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PLAIN RADIOGRAPH1.Readily available and cheap

2.Can show calcification of soft tissues,oblitera

tion of fat planes(acute,active inflammation),bony metastasis,chest and skull involvement


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DRAW BACK

1.Utilizes ionizing radiation( It is anissue with pregnancy)

2.Poor soft tissue contrast andspatial resolution


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CT SCAN

1.Qualitative and quatitative assessment oflesions in the soft tissue of the affected limb

2.The extent of local or distant spread or

involvement can assessed3.Used in staging malignancies

4.Employs iv contrast for opacification of the

blood vessels and increase lesion conspicuity

5.Helical CT to reduce motion artifacts


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DRAW BACKS

1.Expensive and not widely available2.Uses ionizing radiation(It is an issue

with pregnancy)3.Inaccurate history of allergy or

multiple drug reaction when there is

need for contrast.


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ANGIOGRAPHY

1.Can demonstrate neo-vascularization

in masses

2.Lesions in the vasculature can be

determined and interventional

procedures performed immediately

or subsequently.


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DRAW BACKS

1.Highly invasive

2.Uses ionizing radiation(except inMRA).

3.Allergy and multiple drug

reactions


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RADIONUCLIDE IMAGING

1.Soft tissue anomalies with propensity to

develop mineralization can show ectopic

activity on skeletal scintigraphy

e.g,Dermatomyositis,Neoplasia,Myositis

ossificans etc.

2.Helps in assessing the maturity of ectopic

ossification(whether stable )prior tosurgical excision.


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DRAW BACKS

1.Very expensive and rarelyavailable

2.Ionizing radiation


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LYMPHOGRAPHY-Lymphography directly studies the

lymphatic ducts and the internal

architecture of the nodes.

-Used for follow-up imaging of nodal

diseases as the contrast persists in

the nodes for up to 6-12months


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DRAW BACK-False positive results are

frequent occurrence

-The procedure predisposes tooil embolism

-It is very invasive

-Ionizing radiation


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MRI1.Non-ionizing

2.Provides excellent soft tissue contrast and spatial

resolution and has multiplanar capabilities

3.Contrast enhancement using iv contrast can help

in differentiating soft tissue lesions

4.It is the best technique for follow-up

5 INTERVENTIONAL


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5.INTERVENTIONAL

PROCEDURES

Biopsies and Drainage

procedures can be carriedout.


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DRAW BACKS1.Very expensive and rarely available

2.Long image acquisition time

3.Claustrophobic patients

4.Patients with medical prosthesis unless it

is MRI compatible

5.Obese individuals

6.Orthopneic congestive cardiac failure

patients


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RADIOLOGICAL FEATURES

1.PLAIN RADIOGRAPHSoft tissue swelling with the

obliteration of fat plane is seen in

infections and inflammation,in DVT

there is also soft tissue swelling.In

necrotizing fascitis gas is seen withinthe soft tissue swelling.

In dermatomyositis in addition to the


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In dermatomyositis, in addition to thebilateral and symmetrical soft tissueswelling there are sheet-like calcificationsalong fascial and muscle planes.Thedifferentials hereinclude;Scleroderma,Myositisossificans,cysticercosisi,dracunculosis,loiasis,hydatid disease,armillifer

armilatus,leprosy,vascularcalcifications,tendon calcifications,e.t.c.


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ULTRASOUND- B-MODE US

Hypoechoic/sonolucent lesion presentwithin the muscle with or without probetenderness is suggestive of pyomyositis,while

in cellulitis the sonolucent lesion is anterior tothe muscles.In DVT there might bevisualization of the clot or thrombus withinthe vein but the incomplete luminal collapse

following venous compression is an importantpointer to it.Venous diameter at least twicethat of the adjacent artery suggests a

thrombus


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In Rhabdomyolysis there are areas of

reduced echogenicity and non-

homogenous muscle texture.

- COLOUR DOPPLER

There is a peripheral rim pattern of

blood flow seen in pyomyositis.In DVT

there is reduced or absent colour signalor blood flow or a trickle of blood flow

around a thrombus.


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VENOGRAPHY

Intraluminal filling defects( tram-lineappearance) are noted.They are constant

in all the images that show the calf

veins,communicating veins,femoralveins,and iliac veins.These are the

contrast venographic findings in DVT.


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LYMPHOGRAPHY

There is obliteration of lymphaticchannels due to intraluminal

coagulum gel deposition/reactiveinflammation

Filling defects may also be present


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CT SCAN

In infections,heterogenousattenuation of the enlarged soft

tissues with fluid collection(exudate,

or hemorrhage).Rim enhancement

following iv contrast administration is

typical.In Necrotizing fascitis, gas may

be seen along thickened fascial

planes with deep fluid collections.

MRI SCAN


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MRI SCANInfections and inflammations

invariably show high signal intensity

on T2WI and low/intermediate

intensity on T1WI.Fascialthickening(NECROTIZING FASCITIS) is

best demonstrated using thismodality.Peripheral enhancement

with Gadollinium occurs.

RADIONUCLIDE


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RADIONUCLIDE

IMAGINGIt is usefull for demonstratingthrombus in DVT using 99m-

Technitium labelled platelets.

99m-Technetium labelled

nanocolloid show lymphatic

uptake and trapping

INTERVENTIONAL


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INTERVENTIONAL

PROCEDURES1.ANGIOGRAPHY

-Therapeutic embolization of malignancies

-Vascular access allows the introduction of

drugs directly to the site of the

pathology,e.g,Fibrinolytic drugs inDVT,cytotoxic drugs in malignancy,vasodilators

in gangrene.

-Percutaneous transluminal angioplasty can be


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Percutaneous transluminal angioplasty can be

used to treat gangrene

-vena caval filters can be introduced.2.ULTRASOUND SCAN

-Ultrasound guided drainage in the case of

pyomyositis and also biopsy can bedone.Some of the angiographic interventional

procedures involve this modality.

3.CT SCAN

CT guided biopsy

4 MRI SCAN


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4.MRI SCAN

-Biopsy

-Guidance of open surgery


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Multiple

abscessfollowing

pyomyositis.Hy

perintense onT2WI and rim

enhancement

on contrast

administration


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Pyomyositis

Soft tissue

swellinghyperintens

en on T2WI


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PYOMYOSIT

IS,CELLULIT

IS,ANDFASCITIS

ON T2WI

CT SCAN A


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CT SCAN A

CENTRAL

LOWATTENUAT

ING

COLLECTION WITH

ILL

DEFINEDRIM

ENHANCE

MENT


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NECROTIZINGFASCITIS/GAS

GRANGRENE

Swelling ofthe left thigh

with gas

present

NECROTIZING FASCITIS/GAS


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GANGRENE

Fascial thickening on T1WI & T2WI


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Fascial thickening on T1WI & T2WI



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GANGRENE(CT SCAN)


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NEROTIZIN

GFASCITIS/G

AS

GANGRENEGas present

in soft

tissueswelling

T


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Transverse

ultrasound

with dopplershowing

marked

vascularitysurrounding

an anechoic

collection inthe

thigh(abscess)


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CELLULITISHypoechoic

strands

surrounding

hyperechoi

c fat


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DERMATO

MYOSITIS

Swellingand sheet-

like

calcification

PICTURE


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PICTURE

OF THE

SKIN

LESION

ANDPLAIN

RADIOGRA

PH OF THESAME

MAN

DERMATOMYOSITIS


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DERMATOMYOSITIS

DVT


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DVT


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DEEP VENOUS THROMBOSIS


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A.TRANSVERSE POWER DOPPLER IMAGE WITH

TRANSDUCER COMPRESSION APPLIED SHOWS

FLOW IN THE FEMORAL ARTERY(A) AND NO FLOW

IN THE FEMORAL VEIN(V,ARROW).THE VEIN DOES

NOT COMPRESS WITH TRANSDUCER

PRESSURE,INDICATING INTRALUMINAL THROMBUS.

B.ENLARGEMENT OF THE CFV WITH

INTRALUMINAL THROMBUS.


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DVT

Venographywhich

shows fillingdefects and

irregularitie

s in thefemoral vein

LYMPHOEDEMA


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LYMPHOEDEMA

Increased


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signal

intensity inthe

edematousleft leg of a

patient

withlymphoede

ma

Post inflammatory lymphedema of


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Post inflammatory lymphedema of

both limbs

THANK


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THANK

YOU

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