Clinical Examination of Varicose veins

  Clinical Examination of Varicose Veins



1.Age- Middle age

2.Sex- Females – Progesterone

3.Occupation – Standing for long time

4.Duration- Congenital AV Malformation-
                               Klippel-Trenaunay syndrome
                               Local Gigantism. Port wine stain

5.Symptoms-

 1) Pain-2 Types in Varicose vein

1a).Aching pain in the whole leg/Lower leg-particularly towards the end of the day-Relieved by Lying down -Associated with Night Cramps

1b).Bursting Pain while walking-m DVT

2) Swelling- around the ankle joint/Whole limb

3)Ulcer- over the medial malleolus

Excruciating pain over the ulcer - Periostitis

4) Bleeding

5) Itching-Due to Eczema

6) Pigmentation- Lipodermatosclerosis

7) Constipation/Abdominal Distension/ Difficulty in passing urine- Pelvic pathology

8) Fever and Malaise- Thrombophlebitis

9) Cough/ Breathlessness/Hemoptysis/Chestpain-
                                                    Pulmonary Embolism   

10) Deformity- Equinus Deformity


6.Past History

Previous history of Varicose veins- Recurrence
Serious illness requiring prolonged Bed rest/ Hospitalization/ Major  surgery- to rule out DVT

7.Personal History
Obstetric History- previous Pregnancies
OCP Intake

8.Family History
Varicose veins run in Families

General Examination

Look For –Tachycardia ( Feature of AVM)

I.Inspection

1.System Affected

   GSV- Medial Aspect
   SSV-Lateral And Posterior Aspect
   Klippel-Trenaunay - Lateral aspect up to thigh

2. Swelling-

      Localised Swelling

i)A  Segment of superficial Veins dilated  due to Perforator Incompetence 

ii)Thrombophlebitis

      Generalised Swelling-DVT

      Local Gigantism

3.Skin of the Limb

i) Colour-

      Erythema- Thrombophlebitis

      Bluish Hue- DVT ( Phlegmasia cerulea dolens) Toes are spared in DVT

      White/ Pale Hue- Lymphoedema ( Phlegmasia alba dolens) Toes are invariably involved- Crowded Toes in Lymphoedema

ii)Texture of the Skin

      Shiny-Due to DVT

      Thickening- due to Lipodermatosclerosis

      Eczema-

      Ulcerations

      Pigmentations

      Scars

      Loss of Hair & Brittle Nail due to chronic varicosity indicating impending venous gangrene

4. Bulge/ swelling in  the upper medial aspect of the thigh – with exapansile impulse-Saphena Varix


II.Palpation

1. Brodie – Trendelenberg Test 1

Ask the patient to lie down,

Empty the veins by elevating the limbs,

Apply pressure at the SFJ-Using a finger/ tourniquet,

Ask the patient to stand up,

Suddenly release the pressure.

Rapid filling from above indicates a SFJ incompetence.

2.Brodie – Trendelenberg Test2

Ask the patient to lie down,
Empty the veins by elevating the limbs,
Apply pressure at the SFJ-Using a finger/ tourniquet,
Ask the patient to stand up,
Maintain the pressure for 1 minute-
Filling of veins from below indicates Perforator Incompetence.

3. Tourniquet Test

To localise the approximate site of incompetent perforator.
Ask the patient to lie down
Empty the veins by elevating the limbs
Apply 3 Tourniquets
One below SFJ and Mid thigh
One just above the Knee joint
One just below the knee joint
Ask the patient to stand up
Inspect for 30 sec
Take the tourniquet from below upwards
Veins dilate and fill up where the perforator is incompetent.

4.Modified  Perthe’s Test

To know whether the deep veins are normal or not.
Without emptying the veins
Apply the tourniquet at the SFJ
Ask the patient walk for 5 Minutes
Severe crampy  pain and Persistence of varicosities suggest DVT

5. Schwartz Test

In long standing varicose veins if the lower part of the varicosity is tapped, in impulse is felt at the Saphenous opening

6.Pratt’s Test

To know the sites of leg perforators
Esmarch elastic bandage is applied from toes to the groin. This causes emptying of the vein.
Apply the tourniquet at the SFJ
Remove the elastic bandage without removing the tourniquet.
Re apply the elastic bandage from above.
At the positions of perforators visible varices /Blow outs are seen
The sites are marked.

7. Morriyssey’s Cough Impulse Test

Empty the vein by elevating the limb
Limb is kept at 30 degree passive elevation.
Place a finger at SFJ
Ask the patient to Cough forcibly
An expansile impulse is felt at the Saphenous opening
If the SFJ valve is incompetent.
A bruit may be heard on auscultation.

8. Fegan’s Method of Palpation

In standing posture the places of excessive bulges within the varicosities are marked.
Make the patient lie down.
Elevate the limb to empty the veins.
Palpate along the line of marked bulges to find out the pits/defects in the deep fascia which transmits the incompetent perforators.

9.Homan’s Sign-Passive forceful dorsiflexion of foot produce pain in the calf

10.Moses Test- Squeezing of relaxed calf muscles from side to side-causes Tenderness in case of DVT 

11. Local Changes

a.Pitting Oedema, local tenderness on direct palpation-S/o Thrombophlebitis/ DVT

b. Thickening  of the Sub cutaneous tissue-scarring, tissue death and fibrosis.Lipodermatosclerosis.

12.Nicoladonis sign/ Branhams sign-Preesure on proximal part of the artery/feeding vessel will cause reduction in the size of the swelling and disappearance of the bruit-of AVM
Also Pulse rate falls.
Pulse pressure returns to normal.( BP in UL & LL important)
Puse pressure is difference between Systolic and Diastolic blood pressure.

III. Percussion

Schwartz Test- Percuss from below-impulse felt above at SFJ

IV.Auscultation

Bruit on Forcible cough- SFJ incompetence
Machinery murmur- AVM-
Nicoladonis sign-AVM

V.Regional Lymphnode enlargement

VI.Any deformity- Equinus deformity

VII.Other Limb

VIII.Examination of Abdomen- Lumps/Ascitis/ Loaded colon

IX. PV-Fibroid/Ovarian Tumour/Ca Cervix

X.PR- Ca Rectum/ Pelvic deposits/Ca Prostate