Right!

The correct answer is C, popliteal entrapment.

Explanation

Claudication-like symptoms in a young person, especially a muscular male, are likely due to popliteal entrapment. Atherosclerotic obstruction is very unlikely; compartment syndrome generally follows injury and/or reperfusion. Coarctation of the aorta would cause symptoms in both lower extremities. The symptoms of deep venous thrombosis are very different and would not cause a decrease in arterial pressure.

Tutorial

Lower Extremity Arterial Disease: Signs, Symptoms, Risk Factors, and Mechanisms

by

Claudia Rumwell, RN, RVT, FSVU

Michalene McPharlin, RN, RVT, FSVU

Patient History: Signs and Symptoms . . .

1. Chronic occlusive disease:

> Claudication: Pain in muscles occurring during exercise but subsiding with rest. The patient notes muscle fatigue with work, and the discomfort is usually predictable, occurring with the same amount of work and disappearing within minutes of activity cessation. True claudication results from inadequate blood supply to the exercising muscle, which may be caused by arterial spasm, atherosclerosis, arteriosclerosis, or an occlusion. Differential diagnosis includes neurogenic (nerve involvement) and musculoskeletal (called pseudo- [false] claudication) causes that mimic the symptoms produced by vascular claudication. Various types of claudication include:

Buttock claudication, which strongly suggests aortoiliac disease.

Thigh claudication, which suggests distal external iliac/common femoral disease.

Calf claudication, which suggests femoral/popliteal disease.

For example, a patient history may include the note, "2 block claudication," which indicates that the patient complains of pain in a specific part of the leg after walking 2 city blocks.

> Ischemic rest pain: A more severe symptom of diminished blood flow to the most distal portion of the extremity. Pain at rest usually occurs when the limb is not in a dependent position and the patient's blood pressure is decreased (e.g., when sleeping). Symptoms occur in the forefoot, heel, and toes, but not in the calf.

> Tissue loss: Necrosis (tissue death), usually due to a deficient or absent blood supply. Necrosis is the most severe symptom of arterial insufficiency.

2. Acute arterial occlusion:

> Symptoms include the five Ps: pain, pallor, pulselessness, paresthesia, paralysis.

> May result from thrombus, embolism, or trauma.

> This is an emergency situation since the abrupt onset does not provide for the development of collateral channels.

3. Cold sensitivity:

> Symptoms include changes in skin color such as pallor (paleness), cyanosis (bluish discoloration), or rubor (dark red coloration), and the patient often experiences paresthesia and pain. In more severe cases, trophic changes may be evident.

> Raynaud's phenomenon is a condition that exists when symptoms of intermittent ischemia of the fingers or toes occur in response to cold exposure as well as emotional stress.

4. Mesenteric ischemia and renovascular hypertension:

> Mesenteric ischemia is characterized by dull, achy, or crampy abdominal pain that occurs 15 to 30 minutes following a meal.

> Renovascular hypertension is characterized by controlled or uncontrolled hypertension that is often caused by renal artery stenosis or occlusion.

Patient History: Risk Factors and Contributing Diseases . . .

1. Diabetes

2. Hypertension

3. Hyperlipidemia

4. Smoking

5. Family history

6. Other risk factors include age and male gender.

Physical Examination . . .

1. Skin changes—color:

> Pallor is a result of a deficient blood supply. Skin color is pale.

> Rubor, a dark reddish discoloration, suggests damaged, dilated vessels or vessels dilated as a result of reactive hyperemia or infection. Dependent rubor is a specific type of rubor (see Elevation/Dependency Changes below).

> Cyanosis, a bluish discoloration of the skin and mucous membranes, occurs when there is a concentration of deoxygenated hemoglobin.

2. Skin changes—temperature:

The patient's skin should be warm to the touch. It is essential to touch and feel the patient's skin to determine whether it is warm or cold.

3. Skin changes—lesions:

> Ulcerations as a result of arterial insufficiency are usually deep and regular in shape, located over the tibial area, and quite painful compared to venous ulcerations.

> Gangrene is the death of tissue, usually caused by deficient or absent blood supply.

4. Trophic changes:

> Loss of hair on the extremity may reflect poor circulation, although hair loss alone is a poor indicator of peripheral vascular occlusive disease. The skin can also have a shiny, scaly appearance.

> Thickened toe nails.

5. Capillary filling:

Healthy flesh color blanches under manual pressure and normally returns immediately upon release of pressure. If not, decreased arterial perfusion is likely.

6. Elevation/dependency changes:

> Elevating the extremity with impaired circulation produces a cadaveric pallor because of very poor arterial perfusion.

> Returning the extremity to a dependent position causes a slow return to normality followed by the red discoloration called dependent rubor.

7. Palpation (pulses, aneurysms):

> Normal pulses usually signify adequate circulation. Diminished or absent pulses suggest arterial insufficiency.

> Aneurysms are easily palpated and their pulses are bounding.

> Palpable vibration or "thrill" over a pulse site may indicate a fistula, poststenotic turbulence, or even a patent dialysis graft.

> Palpable pulses include the aorta, femoral, popliteal, dorsalis pedis, and posterior tibial arteries. The peroneal artery cannot be palpated.

8. Auscultation (bruits):

> Bruits are abnormal, low-frequency sounds heard on auscultation. They are distinct from the normal lub-dub sound and can be caused by significant stenosis that causes vibration in the tissue distal to the stenosis. Because bruits are low-frequency, and depending on the examiner's hearing range, they may or may not always be heard.

> Sites for auscultation include the carotid, abdominal aorta, femoral, and popliteal arteries.

> The absence of a bruit suggests normality but cannot rule out disease. In cases of severe stenosis, usually greater than 90% diameter reduction, the bruit disappears.

> Poor cardiac output can decrease the strength of the bruit, making bruit auscultation difficult or impossible.

Mechanisms of Peripheral Arterial Disease . . .

1. Atherosclerosis

2. Embolism

3. Aneurysm

4. Arteritis

5. Coarctation of the aorta

6. Vasospastic disorders/cold sensitivity, i.e., Raynaud's phenomenon, which may be idiopathic (arterial spasm) or related to an underlying disease or anatomic abnormality (leading to arterial obstruction)

7. Entrapment syndromes (e.g., popliteal entrapment syndrome)

Sources

Ridgway DP, Bean BA, Owen CA, Strandness DE Jr: Vascular Technology CD-ROM Mock Exam. Pasadena, CA Davies Publishing, 2008.

Rumwell CB, McPharlin M: Vascular Technology: An Illustrated Review, 3rd ed. Pasadena, CA, Davies Publishing, 2004, p 111.