Examination of extremities

Oedemas
 
Digits (fingers, toes)
 
Nails
 
Skin
 
Muscles
 
Vessels
 
Joints

Extremities are symmetrical, without oedemas and skin disorders, well supplied with blood, and freely mobile.
 
Further described changes generally occur in lower extremities.
 
Oedemas
 

	Symmetrical - at first perimalleolar, gradually extending as far as the thigh, occur in right-sided heart failure. They are tougher, sore, the skin is colder or cyanotic, in recumbent patients they are found on the lower side of calves and thighs. On their decline, the skin "gets shrunken".
	Symmetrical - in lower extremities, softer with persisting depression on palpation, occur in hypoproteinemia and cardiac insufficiency, they change in dependence on the position.
	Both symmetrical and asymmetrical - tough in upper or lower extremities, the extent and localisation depend on the block of lymphatic drainage (lymphoedema).
	Unilateral oedema - mostly in lower extremities (calf and often also thigh), the skin colour unchanged with transparent superficial venous pattern, tense, the temperature comparable or slightly higher if compared with the opposite side. Deep palpation of the calf is painful, as well as dorsiflexion (Homans´s sign), the middle of the sole is also tender on palpation (plantar sign).   The mentioned symptoms are not specific, but their presence suggests possible deep vein thrombosis (DVT) - phlebothrombosis.   DVT of a various extent can also occur in upper extremities (i.v. application, taking blood samples, cannulation of a peripheral vessel).   Unilateral oedema of a small extent can be connected with thrombophlebitis, manifested, moreover, in skin erythema and pain (varixes, cannulation of peripheral vessel, i.v. injection).

Oedema of lower
extremities
 

Cardiac oedemas
of lower
extremities
 

Shrunken skin
in lower
extremities
after the decline
of oedemas
 

Lymphoedema
of lower
extremity
 

Lymphoedema
of lower
extremity -
detail
 

Bilateral
lymphoedema
(congenital)
 

Lymphoedema
of lower
extremity
 

Deep venous
thrombosis
 

Obesity,
phlebo-thrombosis
of the left arm

Digits
 
Digits of upper as well as lower extremities are axially symmetrical, nails slightly arched, smooth, firm, with proportional representation of the lunula.
 
Clubbed distended digits with spherical nails, mostly cyanotic, occur in congenital cardiac defects and bronchopulmonary diseases.
 
Amputated - they are ablated (onycho-ectomy) usually due to serious ischaemic changes in diabetic patients or in ischaemic vascular disease of lower extremities.

Detail -
digital clubbing
in congenital
cardiac effect
 

Digital clubbing -
central cyanosis
 

Digital clubbing
in lower
extremity
 

Condition after
amputation of toes
(diabetic
microangiopathy)
 

Amputated toes
in a diabetic
patient

Nails
 
Koilonychia (spoon nails) - occur in thyrotoxicosis.
 
Cera guttans - lengthwise grooving alternated with shallow depressions. These changes are present in rheumatoid arthritis.
 
Onychomycosis - is manifested with uneven, friable nails, changed in colour, single or multiple nails are affected, mostly in lower extremities.
 
Hepatic - whitish part of the nail (lunula) occupies a substantial part, can be found in patients with liver cirrhosis.
 
Splinter haematomas - occur in chronic infectious endocarditis (embolisation).

Onychomycosis
of the big toe
of the right foot
 

Splinter
haematomas

Skin
 
Skin on the extremities is pink, warm, firm, elastic with retained skin appendices (adnexa).
 
Trophic changes - the skin is drier, colder, desquamated, hair scarce or absent, presence of skin defects (ischaemic vascular disease of lower extremities, diabetic angiopathy).
 
Changes in colour
 

	The skin is pale, colder in comparison with the surrounding.
	The skin is marbled or cyanotic, in the extent corresponding with ischaemia (focuses, single or multiple digits - findings usual in ischaemic vascular disease of lower extremities).
	The skin is hyperpigmented, usually on legs, in the lower 1/2 to 1/3 of the crus, focuses of haemosiderin are of various size depending on aetiology. In the area of healed varicose ulcers, they are more extensive.
	Palmar erythema is pinkish red, in palms (thenar, antithenar) it occurs in liver cirrhosis.

Ischaemic
disease of lower
extremities -
dry necrosis
of the big toe
 

Ischaemic
disease of lower
extremities
 

Cyanosis,
ischaemia
 

Dry gangrene
of the big toe
 

Microbial eczema
in the area of
chronic vascular
insufficiency
 

Hyperpigmentation
of the crura
 

Palmar
erythema

Varixes are manifested as single bluish transparent subcutaneous nodes or as stem varicosity of v. saphena magna (great saphenous vein). Its filling is increased in standing position. Erythema (reddening) of the skin above them and the infiltrate following the course of the vein, is a manifestation of thrombophlebitis.
 
Inflammatory changes
 

	Erysipelas is an inflammation of the skin and epidermis caused by streptococcal infection, manifested in a rose-violet coloration, the margin of the inflammation is tongue-like projected against the healthy skin.
	Erythema nodosum are tough infiltrates of a mauve colour prominent over the level of skin of the crura, occurring in idiopathic intestinal inflammation.
	Psoriasis vulgaris is manifested on the skin of knees and elbows, in a smaller extent also in other locations, grey-pink skin changes are of various shapes, they gradually desquamate.
	Interdigital mycoses are found mostly between foot toes, they cause rhagades or minor blisters.
	Dupuytren's contractures occur in the palms of hands, they look like hardened stripes running towards some fingers (mostly to the 3rd and 4th). Sometimes the movement of fingers is therefore limited. They occur in elderly people, more frequently in liver cirrhosis.
	Multicolour skin changes - in the form of various skin efflorescences sometimes occure in vasculitis or they can be a paraneoplastic manifestation.
	Hyperkeratosis related changes - keratoma palmare.

Crural ulcer
 

Crural ulcer
 

Venous varixes
 

Erythema nodosum
in legs
 

Erythema nodosum
in legs
 

Psoriasis
in the crura
 

Dupuytren's
contracture,
palmar erythema,
tattooing on the
forearm
 

Dupuytren's
contractures
 

Keratoma palmare

Scars on the skin are of various size, shape and origin.    Flat, atrophic - in the lower part of the crura, originate after healing of crural varicose ulcers. Hyperpigmentation is more frequent in their surrounding;    Postoperative    Short - at the internal side of the crura or thighs, correspond with extirpation of varixes;    Long at the internal sides of both crura due to extirpation of v. saphena magna (used for revascularisation cardiosurgery).    Long over the hip or knee joints following orthopaedic surgery (total endoprosthesis of the respective joint).    Of irregular shape and localization are connected with traumas.

 
Musculature
 
The muscles of extremities are proportionately developed, symmetrical with adequate muscular tonus.
 
Muscular atrophy - of a small or greater extent is developed in an inactive limb (immobility in vascular cerebral emergencies, in lack of movement due painful articular syndrome, etc.).
 
Muscular hypertrophy - occurs in atypical exertion of the limb (orthopaedic defects, paresis).
 
Vessels - arteries
 
Arterial pulsation is well palpable in typical localisations.
 
Reduced pulsation signals narrowing of the lumen, most often due to an arteriosclerotic plaque or thrombus.
 
Palpation is used for examination of a. femoralis, a. poplitea, a. dorsalis and a. tibialis posterior. Ischaemic changes develop in accordance with the severity of circulation disorder.
 
More detailed information on blood supply is provided by Doppler ultrasonography of the malleolar pressure (physiological finding is by 10 to 30 mm Hg higher compared to the arm).
 

Scars after
venous grafts
withdrawal
 

Scar in the
left arm
 

Scars after
venous grafts
withdrawal

Joints
 
Visible joints are of proper sublime shape, freely mobile.
 
Deformation of a joint is caused by the presence of osteophytes, exostoses; the movement is reduced, scratching sounds (knee, astragalus) can be heard on palpation.
 
Heberden´s nodes represent arthritis of the distal interphalangeal joints.
 
Bouchard´s nodes affect the proximal interphalangeal joints, which are irregularly roughened.
 
Halluces valgi a deformation of the 1^st metatarsophalangeal joint of the foot with deviation of toes (occur in pes planus, improper shoes, or in genetic disposition).
 
Spindle-shaped (fusiform) swelling (intumescentia) of the joint is caused by an inflammation. Frequent affection is found in proximal interphalangeal joints in rheumatoid arthritis. Chronic character of the disease causes ulnar deviations, later desaxations, in the worst case even articular ankyloses. Interosseous hand muscles are atrophic.
 
Gout related tophi look like whitish nodules over joints of hands. They are caused by deposition of uric acid crystals (gout).

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Deformation of the
wrist of the
right upper
extremity afer
Colles' fracture
 

 

Revmatoid
arthritis
 

Revmatoid
arthritis
 

Polyarthritis
of the hand -
gouty tophus