the patient with swollen leg(s)

see also:

• deep venous thrombosis (DVT)
• congestive cardiac failure
• nephrotic syndrome
• pre-eclampsia and eclampsia
• venous insufficiency of the leg

• the patient with swollen leg or legs, or peripheral oedema is a common presentation to the ED
• it is usual to assess whether the swelling is bilateral or not and if there is pitting oedema
  • non-pitting oedema suggests lipoedema, obesity, myxoedema or advanced fibrotic forms of lymphedema / lymphoedema
• most cases are NOT painful but deep venous thrombosis (DVT), cellulitis, traumatic causes, compartment syndrome, lipoedema and reflex sympathetic dystrophy (RSD) / complex regional pain syndrome / causalgia ARE painful while venous insufficiency of the leg is often associated with low grade ache
• venous oedema is more likely than lymphoedema to improve overnight with elevation of legs
• a warty texture (hyperkeratosis) with papillomatosis and brawny induration are characteristic of chronic lymphoedema
• brown haemosiderin deposits on the lower legs and ankles are consistent with venous insufficiency
• increased sweating suggests acute phases of reflex sympathetic dystrophy (RSD) / complex regional pain syndrome / causalgia

• trauma - haematoma
• compartment syndrome
• ruptured medial head of gastrocnemius
• joint effusion
• ruptured Baker's cyst
• deep venous thrombosis (DVT)
• cellulitis
• chronic causes:
  • venous insufficiency of the leg
  • lymphedema / lymphoedema:
    • tumour
    • radiotherapy
    • surgery
    • post-infection
    • idiopathic
  • pressure on iliac vein:
    • unilateral pelvic mass such as ovarian tumours, lymphoma
  • reflex sympathetic dystrophy (RSD) / complex regional pain syndrome / causalgia

• raised central venous pressures:
  • due to sodium and water overload / retention with increased extracellular fluid volume (ECFV)
    • chronic renal failure
    • acute kidney injury (AKI) / acute renal failure (ARF)
    • congestive cardiac failure
    • iatrogenic
  • due to cardiac failure
    • congestive cardiac failure
    • cor pulmonale
• venous insufficiency of the leg +/- exacerbated by:
  • prolonged dependency
  • calcium channel blockers
  • non-steroidal anti-inflammatory drugs (NSAIDs)
  • corticosteroids
  • beta adrenergic blockers
  • clonidine (Catapres)
  • hydralazine
  • minoxidil
  • progestogens
  • oestrogens
  • tesosterone
  • glitazone oral hypoglycaemic agents
  • monoamine oxidase inhibitors (MAOIs)
• deep venous thrombosis (DVT) if either:
  • extensive and involving the IVC causing bilateral oedema
  • bilateral DVT's
• pelvic mass causing pressure on iliac veins
  • pregnancy
  • ovarian tumours
  • uterine cancer
• lymphedema / lymphoedema:
  • idiopathic
  • lymphoma
  • radiotherapy
  • post-surgical
  • post-infective
  • filariasis
• lipoedema
• obesity
• hypoalbuminaemia
  • cirrhosis
  • nephrotic syndrome
• pre-eclampsia and eclampsia
• hypothyroidism - myxoedema