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Case 87: Painful leg

This patient has presented with leg pain.

1. Which leg do you think is painful?

The right one. Or the one that is absolutely completely white. The left leg has a mottled appearance, which may be due to chronic arterial insufficiency or due to this patients acute illness and peripheral shutdown. On examining this patient they will demonstrate a pale, pulseless, paralysed, painful and perishingly cold leg

2. How would you manage this patient?

As for an acutely ischaemic limb.

This is a surgical emergency with a high associated mortality.

The issues are
1. Usually elderly unwell patients
2. with multiple co-morbidities
3. They are often systemically unwell with this episode
4. in enormous pain
5. and at risk of other emboli (eg stroke, mesenteric infarct) if thought to be embolic in nature.


They need urgent resuscitation, analgesia, delineation of the level of occlusion, restoration of limb blood flow, control of reperfusion sequelae, which may also involve fasciotomies. Also anticoagulation and control of embolic source if indicated.

The occasional patient will be too unwell for this treatment and will be best treated by palliation.





Further Reading
Guidelines for the management of patients with peripheral arterial disease
PubMed : Acute lower limb ischaemia