The signs of an acute arterial occlusion are the five Ps: pain, pallor, paresthesia, paralysis, and pulselessness.
Chronic progressive small vessel disease is characteristic of diabetes mellitus. It is commonly observed that arterial pulses are present despite gangrene in the extremity. Figure 15-14 depicts dry gangrene of the toes in a diabetic patient.
Diabetes has been associated with many skin disorders. The cutaneous hallmark of diabetes is a waxy, yellow or reddish-brown, sharply demarcated, plaquelike lesion known as necrobiosis lipoidica diabeticorum. These lesions are classically found on the anterior surface of the lower legs. They are shiny and atrophic, with marked telangiectasia over their surface. The lesions have a tendency to ulcerate, and the ulcers, once present, heal very slowly. Necrobiosis lipoi-dica diabeticorum often predates the development of frank diabetes. The severity of the cutaneous lesion is not related to the severity of the diabetes. Figure 15-15 shows necrobiosis lipoidica diabeticorum;Figure 15-16 is a close-up photograph of the lesion in another patient with diabetes.
Deep vein thrombosis of a lower extremity is diagnosed when there is unilateral marked swelling, venous distention, erythema, pain, increased warmth, and tenderness. There is often resistance to dorsiflexion of the ankle. Calf swelling is present in most patients with femoral or popliteal venous involvement, whereas thigh swelling occurs with iliofemoral thrombosis. Figure 15-17 shows deep femoral vein thrombosis secondary to cancer. Notice the marked swelling of the left leg.
Gentle squeezing of the affected calf or slow dorsiflexion of the ankle may produce calf pain in approximately 50% of patients with femoral vein thrombosis. Pain elicited by this technique is referred to as Homans' sign. Unfortunately, owing to the low sensitivity of Homans' sign, this finding should not be used as a single criterion for diagnosing deep vein thrombophlebitis. A variety of unrelated conditions also may elicit a false-positive response.
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