Clinical Review ABC of arterial and venous disease

Swollen lower limb—1: General assessment and deep vein thrombosis

BMJ 2000; 320 doi: https://doi.org/10.1136/bmj.320.7247.1453 (Published 27 May 2000) Cite this as: BMJ 2000;320:1453

This article has a correction. Please see:

  1. W Peter Gorman,
  2. Karl R Davis,
  3. Richard Donnelly

    The most common cause of leg swelling is oedema, but expansion of all or part of a limb may be due to an increase in any tissue component (muscle, fat, blood, etc). A correct diagnosis requires consideration of whether the swelling is acute or chronic, symmetrical or asymmetrical, localised or generalised, and congenital or acquired. Chronic swelling, particularly if asymmetrical, is usually a sign of chronic oedema arising from venous or lymphatic disease, whereas symmetrical lower limb swelling suggests a systemic or more central cause of oedema, such as heart failure or nephrotic syndrome. Oedema develops when the rate of capillary filtration (lymph formation) exceeds lymphatic drainage, either because of increased capillary filtration, inadequate lymphatic flow, or both. Extracellular fluid volume is controlled prinicpally by the lymphatic system, which normally compensates for increases in capillary filtration. Most oedemas arise because filtration overwhelms the lymph drainage system. Increased capillary filtration may occur because of raised venous pressure, hypoalbuminaemia, or increased capillary permeability due to local inflammation. The two main causes of a swollen lower limb are deep vein thrombosis and lymphoedema (a failure of the lymph drainage system). This article concentrates on deep vein thrombosis and next week's article on lymphoedema.

    Causes of swelling of lower limb

    Acute
    • Deep vein thrombosis

    • Cellulitis

    • Superficial thrombophlebitis

    • Joint effusion or haemarthrosis

    • Haematoma

    • Baker's cyst

    • Torn gastrocnemius muscle

    • Arthritis

    • Fracture

    • Acute arterial ischaemia

    • Dermatitis

    Chronic
    Congenital vascular abnormalities
    • Haemangioma

    • Klippel-Trenaunay syndrome

    Venous disease
    • Post-thrombotic syndrome

    • Lipodermatosclerosis

    • Chronic venous insufficiency

    • Venous obstruction

    Lymphoedema
    • Cancer treatment

    • Infection

    • Tumour

    • Trauma

    • Pretibial myxoedema

    Other
    • Heart failure

    • Reflex sympathetic dystrophy

    • Idiopathic oedema of women

    • Hypoproteinaemia, such as cirrhosis, nephrotic syndrome

    • Armchair legs

    • Lipoedema

    Deep vein thrombosis

    Thrombosis usually develops as a result of venous stasis or slow flowing blood around venous valve sinuses; extension of the primary thrombus occurs within or between the deep and superficial veins of the leg and the propagating clot causes venous obstruction, damage …

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