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MDS 1008 - Clinical examination of the arteries and superficial veins nervesreflexes of the lower limb

The Arteries
The arterial system important to palpate the peripheral pulses for
atherosclerosis (suspecting peripheral vascular disease) were arteries may be weak
or not felt, prior to coronary angiography you would need to palpate the artery,
access for insertion of femoral lines for e.g. for use in dialysis or invasive blood
pressure monitoring. These are all reasons why arteries are important.
1. Palpate the femoral artery at the mid-inguinal point ie half way between the
anterior superior iliac supine and the pubic symphysis. Palpate below the
inguinal canal. Pulse on one side is then compared on the other side. When
the femoral artery passes through the adductior hiatus, it is more
susceptible to atherosclerosis. If suspecting atherosclerosis and feel that
pulse is reduced or absent, using a stethoscope you listen for a bury
2. Palpating the popliteal pulse, put thumbs on tibial tubercle, ask patient to
flex the knee but is relaxed. Press hard to feel. Use all 8 fingers
3. Palpating the dorsalis pedis; area between 1 st and 2nd metatarsals and palpate
them using 3 fingers
4. Palpating the posterior tibial; go half way between the medial malleoulus and
the medial side of prominence always compare to the other side.
If diseases is in the femoral and more distally, the calf will get intermittent
claudication. It would be relieved on walking but if severe, it can become rest pain
Veins of the Leg
Deep and superficial system is connected by perforating veins having one way
valves so that when blood flow from one system to the other, the amount of blood
which goes back is less. When the valves are dilated, they wont be able to close
properly and so there is always back flow of blood into the superficial system and
keeps becoming more dilating. This leads to the formation of varicose veins.
Distribution of great saphenous veins goes from the dorsal venous plexus, medially
passing anterior to the medial mallelous and keep going up to pass posterior to the
knee and then enters the femoral vein. Great saphenous vein is used in a great
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venous cut down. In patients who are losing a lot of blood wont be able to locate a
good vein to insert a cannula. In such case the sapehnous vein is located and opened
quickly surgically and insert the cannula anterior to the medial mallelous. Nowadays,
new techniques are being used.
Distribution of the short sapehnous passes from the dorsal venous, goes up and
apsses posterior to the lateral mallelous and keeps going up at the back; midline of
the posterior calf and enters the popliteal vein by pieceing the deep fascia at the
popliteal fossa.
Deep veins: divide into the femoral vein, popliteal vein which divides into the
posterior tibial, the tibularis and the
Short saphenous joins the popliteal veins
Neurological System of the Leg
1.
2.
3.
4.
5.
6.

First inspect for any fasciulaitons of the muscles, muscle wasting, drop foot.
Asses the tone
Power
Reflexes
Coordination
Sensation

If patient is hypertonic, the whole leg will go up if you just pull the knee.
Check the power by examining the different parts of the leg; hip flexion and
extension, knee flexion and extension and plantar flexion and extension. By doing
this you would be examining the different nerve roots.

Hip flexion L1, L2

Knee Extension L3, L4
Hip Extension and knee flexion - L5,S1
Extension of the big finger L5

To asses the power you use the grade which is graded from 0-5

Reflexes

Knee Jerk: Looking for hyper-reflexia (could indicate a stroke in the past),
normal or reduced/absent.
Ankle Jerk: needs to be dorsi-flexed first

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Babinski reflex: toes extended would be a positive babinski. Up going

plantars which is a sign of upper motor neuron lescion. Same as having hyperreflexia at the knee.

Co-ordination
Looking for pathology in the cerebellum
The different sensory modalities: Soft touch, pain, vibration tested with a tunning
fork, joint-positioning sense and temperature. Take a systemic approach along the
dermatomes. Do this using a cotton wool. To test a different modality use a pin
prick.
Above the ASIS Dermatome T 12. L1 L2, L3 at the knee, at the medial side of leg
L4, L5 at lateral side of leg, S1 on toes.
Peripheral neuropathy; decreased sensation of their peripherals if they have
severe, chronic, uncontrolled diabetes.
Ulcer at the heel. The heel is a pressure point and so it may be a pressure ulcer
due to peripheral vascular disease.
A possible complication of DVT is pulmonary embolism.