Is It Normal to Feel Pulse Agains Your Leg Bone and Skin

Definition

Assessment of the peripheral vascular system is done to determine the characteristics of the pulse, to define the presence of an arterial bruit(due south), and to detect the occurrence of venous inflammation with possible secondary thrombosis of that vein.

Increases in pulse rate (tachycardia) may advise hyperthyroidism, feet, infection, anemia, or arteriovenous fistula. Slowing of the pulse charge per unit (bradycardia) may be seen in centre block, hypothyroidism, or with the apply of sure drugs (eastward.g., propranolol). Irregularities in the pulse suggest the presence of premature beats, and a completely irregular pulse implies the presence of atrial fibrillation. Macerated or absent pulses in the diverse arteries examined may be indicative of impaired blood catamenia due to a variety of conditions.

Bruits are rushing sounds heard over large and medium-sized arteries as a upshot of vibration in the vessel wall caused by turbulent blood flow. The sound may originate from a local narrowing or dilation of the vessel itself, or it may be transmitted along the artery from a more proximal lesion in the vascular organisation. The intensity and duration of the bruit relate to the degree of vessel wall baloney. In full general, bruits are not audible until an artery is approximately fifty% occluded. The sound increases in pitch as the lumen becomes more than narrowed to a critical size. Thereafter, the sound may no longer exist detectable as the volume of blood flow becomes profoundly reduced.

Technique

Pulses

A complete physical test includes the cess and recording of arterial pulses in all locations. While examining the pulse, the observer should note its intensity, rate, rhythm, and if any claret vessel tenderness, tortuosity, or nodularity exists. It is unreliable to attempt to estimate blood pressure via arterial palpation without the use of the sphygmomanometer.

The patient should exist examined in a warm room with arrangements made so that the patient's pulses can easily exist examined from both sides of the bed. A cool environment may cause peripheral vasoconstriction and reduce the peripheral pulse. Palpation should be washed using the fingertips and intensity of the pulse graded on a scale of 0 to 4 +:0 indicating no palpable pulse; 1 + indicating a faint, but detectable pulse; 2 + suggesting a slightly more than diminished pulse than normal; three + is a normal pulse; and 4 + indicating a bounding pulse.

The student examiner must be alert to the possibility that the pulse he or she feels may be due to digital avenue pulsations in his ain fingertips; this source of confusion can exist eliminated by comparing the pulse in question to his own radial pulse or to the patient's cardiac sounds equally determined by auscultation over the precordium. In full general, it is inadvisable to employ the thumb in palpating for peripheral pulses. The pollex carries a greater likelihood of confusion with the examiner's ain pulse and generally has less discriminating sensation than the fingers. Oftentimes, inspection will be an aid to pulse location. The examiner may be able to meet the skin ascent and fall with each pulsation along the course of an extremity artery, especially if a bright light is aimed tangentially beyond the surface of the skin.

To examine the brachial artery (Figure 30.i) in the correct arm, the examiner supports the patient'south forearm in his left hand, with the subject'due south upper arm abducted, the elbow slightly flexed, and the forearm externally rotated. The examiner'due south right paw is and then curled over the anterior attribute of the elbow to palpate along the grade of the artery just medial to the biceps tendon and lateral to the medial epicondyle of the humerus. The position of the hands should be switched when examining the contrary limb (Figure 30.1).

For the radial avenue (Effigy 30.2), the patient's forearm should be supported in ane of the examiner's hands and his other paw used to palpate along the radialvolar attribute of the subject'southward forearm at the wrist. This tin can all-time be done past curling the fingers effectually the distal radius from the dorsal toward the volar aspect, with the tips of the first, second, and third fingers aligned longitudinally over the course of the avenue.

The abdominal aorta (Figure xxx.3) is an upper intestinal, retroperitoneal structure which is best palpated by applying firm pressure level with the flattened fingers of both easily to indent the epigastrium toward the vertebral column. For this examination, it is essential that the discipline's abdominal muscles be completely relaxed; such relaxation tin be encouraged by having the subject flex the hips and by providing a pillow to support the caput. In extremely obese individuals or in those with massive abdominal musculature, it may be incommunicable to detect aortic pulsation. Auscultation should be performed over the aorta and along both iliac vessels into the lower abdominal quadrants.

The mutual femoral avenue (Figure 30.4 emerges into the upper thigh from below the inguinal ligament one-3rd of the distance from the pubis to the anterior superior iliac spine. Information technology is best palpated with the examiner standing on the ipsilateral side of the patient and the fingertips of the examining paw pressed firmly into the groin. Auscultation should be performed in this area, as well.

The popliteal artery (Effigy xxx.5) passes vertically through the deep portion of the popliteal infinite just lateral to the midplane. It may be hard or impossible to palpate in obese or very muscular individuals. Generally this pulse is felt most conveniently with the patient in the supine position and the examiner'south hands encircling and supporting the knee joint from each side. The pulse is detected by pressing securely into the popliteal space with the supporting fingertips. Since complete relaxation of the muscles is essential to this examination, the patient should be instructed to let the leg "get limp" and to allow the examiner to provide all the support needed.

The posterior tibial artery (Effigy 30.6) lies just posterior to the medial malleolus. It tin can exist felt almost readily past curling the fingers of the examining hand anteriorly around the talocrural joint, indenting the soft tissues in the infinite between the medial malleolus and the Achilles tendon, above the calcaneus. The thumb is applied to the opposite side of the talocrural joint in a grasping fashion to provide stability. Again, obesity or edema may prevent successful detection of the pulse at the location.

The dorsalis pedis artery (Effigy 30.7) is examined with the patient in the recumbent position and the ankle relaxed. The examiner stands at the foot of the examining table and places the fingertips transversely beyond the dorsum of the forefoot near the ankle. The avenue usually lies near the middle of the long axis of the foot, lateral to the extensor hallucis tendon merely it may be abnormal in location and often requires some searching. This pulse is congenitally absent in approximately ten% of individuals.

Bruits

After palpating the artery, auscultation for a bruit should exist performed. Bruits are detected past auscultation over the big and medium-sized arteries (e.chiliad., carotid, brachial, intestinal aorta, femoral) with the diaphragm of the stethoscope using light to moderate pressure level. Excessive pressure may produce, intensify, or foreclose a bruit from being detected past indenting the vessel wall or occluding blood menstruum in the avenue. One should mind over the artery after palpation of the avenue to avoid overlooking a pregnant lesion.

Occasionally, bruits are audible over the upper abdomen in immature, healthy individuals. These sounds apparently originate from tortuous vessels and are of no clinical significance; if the subject has a normal blood pressure and is free of abdominal symptoms, such findings may be overlooked.

Oft the examiner will detect a "thrill" or palpable vibratory sensation over a vessel in which a loud bruit is audible. The thrill is indicative of marked turbulence in local blood flow and suggests significant vascular pathology. If a thrill is noted during exam of the pulses, it should exist recorded in the advisable space on the data base.

Phlebitis

With the patient supine, the veins of the extremities usually cannot be palpated just can be examined by inspection. Phlebitis most commonly occurs in the superficial arm veins and the deep veins of the lower extremity.

Arm vein phlebitis is suggested by noting erythema occurring along the grade of the vein, which may be tender to palpation if secondary venous thrombosis has occurred; this may be palpable (i.e., a "string").

Lower extremity thrombophlebitis tin can be clinically silent and may be very hard to detect by physical examination. Changes secondary to the venous obstruction may develop and be observed as increased thigh or dogie girth, erythema, warmth, tenderness, or palpation of a cord. Numerous laboratory techniques have been developed to aid the medico in the search for lower extremity thrombophlebitis.

Measurement of calf circumference should be obtained in all patients with suspected lower extremity thrombophlebitis. This should be washed with the patient standing and the anxiety 30 cm apart. The maximum circumference is recorded and a significant difference exists if the two sides differ by ane.five cm in males and 1.two cm in females.

Pare erythema or warmth may be noted in agile phlebitis. A thrombosed segment of vein (i.e., a cord) may be palpable, specially in the superficial veins of the lower extremity.

Pain is a prominent feature of muscular, synovial, or vascular leg disease and various tests accept been suggested to help identify the specific etiology. Homan's examination (dorsiflexion sign) is most popularly used to find irritability of the posterior leg muscles through which inflamed or thrombosed veins course. A popular clinical misconception is that calf pain is the endpoint of the test; however, Homan clearly stated that "discomfort need have no part in this reaction." A positive sign is when dorsiflexion of the foot on the afflicted side is less complete or is met with more resistance than on the unaffected side. Resistance to dorsiflexion may also be manifested by involuntary flexion of the genu.

The Lowenberg gage test is another helpful clinical maneuver for detection of dogie vein thrombosis. Wrap a blood pressure gage around the thigh just above the knee, taking intendance non to compression the skin backside the knee. Close the valve and inflate the cuff gradually to 180 mm Hg. Enquire the patient to tell you of any unusual discomfort. Minimal discomfort immediately under the cuff is mutual. Spontaneous complaint of calf hurting at 20 to lxxx mm Hg (that is, to a higher place venous force per unit area) is highly suggestive of local venous disease, peculiarly if 150 to 180 mm Hg contralateral thigh pressure level is well tolerated.

Other symptoms and signs include Moses" test (dogie hurting greater with anteroposterior than side-to-side palpation), localized leg hurting on cough (Lawrence'due south sign), and tenderness to touch in the sole of the foot (Owane's sign).

Basic Science

The deep veins of the lower leg include the paired inductive tibial, posterior tibial, and peroneal veins that course aslope the tibia and fibula through the soleus and gastrocnemius muscles. Those veins join to class the deep popliteal vein behind the knee. The popliteal vein so drains into the superficial and common femoral vein and on to the external iliac vein, junior vena cava, correct heart chambers, and pulmonary arteries.

The superficial veins of the lower leg include the long (greater) and brusque (lesser) saphenous. The long saphenous vein is usually visible but anterior to the medial malleolus of the foot. It courses superficially upward the leg until joining the common femoral vein near the inguinal ligament. The short saphenous vein is ofttimes visible just posterior to the lateral malleolus of the foot. Information technology courses up the lateral leg aspect to bring together the popliteal vein backside the human knee.

On placidity standing, the venous pressure approaches 120 cm H₂O in the lower leg veins. This is reduced to 20 cm H_twoO during walking. The loftier dependent venous force per unit area accounts for claret flows of only 4.0 cm/sec. Venous return upward the leg is assisted by muscular contractions that squeeze claret far enough upwardly the veins to be trapped by bicuspid venous valves, so spurted upwardly again past the next muscular contraction. These valves are typically present in both superficial and deep leg veins as far proximally as the external iliac vein.

Venous stasis and slow flow advance thrombus formation. Information technology is therefore not surprising that diverse "hypercoagulable" clinical states are associated with thrombosis of the deep leg or other low-flow systemic veins. Thrombosis is farther accelerated by either traumatic or inflammatory injury to the venous endothelium such that platelet assemblage and fibrin formation are enhanced.

Since thrombosis in the calf veins is usually asymptomatic, an acute clinician should exist aware of its potential presence given appropriately suspicious clinical settings. Examples would include the post-obit:

1. Any recent leg trauma

   1. Fractures of the tibia, fibula, femur, or hip

   2. Soft-tissue leg injuries

   3. Ankle sprains

2. Venous stasis and relative leg muscle immobility

   1. Bed confinement

   2. Postoperative

   3. Postpartum

   4. Varicose veins or chronic venous insufficiency

   5. Prolonged motorcar, truck, or double-decker trips, high strap boots, extended Television viewing with crossed legs

3. Certain drugs

   1. Postdiuresis

   2. Corticosteroids

   3. Estrogen-containing oral contraceptives, particularly high-dose

4. Malignancy

Clinical Significance

Examination of the pulse can provide clues to the presence of systemic diseases. Ancient physicians would diagnose middle, liver, renal, and gastrointestinal problems from cess of the pulse. Today, other tests have been developed to assist in the work-up of systemic illness, but examination of the pulse is even so an important office of patient cess.

Conditions associated with tachycardia or bradycardia have been discussed, as have the causes of a pulse irregularity. Reduced or absent arterial pulses are a sign of dumb blood menses. The causes include: (1) congenital abnormalities (coarctation of the aorta, anomalous peripheral arteries); (2) intrinsic arterial illness (atherosclerosis, thrombosis, arteritis); (3) vasospastic disorders (Raynaud'due south phenomenon); or (four) involvement of the vessel by extrinsic compression (thoracic outlet syndrome, trauma, neoplasms). The resultant alteration of pulses, with or without accompanying bruits, may exist indicative of either acute or chronic changes in a given patient. The vascular history, together with associated concrete findings such every bit skin color, temperature, and neuromotor condition of the extremity, should help to elucidate these points. More than refined diagnostic techniques such as Doppler ultrasound examination and arteriography may be required to evaluate abnormalities suspected from the physical examination. In this regard, information technology is important to understand that significant arterial occlusive affliction of the lower extremities may be in a patient who has almost normal peripheral pulses in the resting state, since collateral circulation can produce pulsatile flow in the peripheral arterial bed in some patients. If such an individual is instructed to exercise to the point of claudication, even so, pulse distal to the major vascular occlusion will diminish or disappear.

Significant widening of an artery to the examining fingers may exist the best inkling to an otherwise silent arterial aneurysm. The wary examiner volition not exist misled past tortuosity of the vessel giving a false impression of increased diameter. Conscientious palpation may likewise reveal the rock-hard vessel wall of calcified atherosclerosis, the harsh systolic thrill of a tight arterial stenosis, or the continuous thrill of a peripheral arteriovenous fistula. In the latter condition, auscultation should confirm a continuous, or mechanism-like, murmur with systolic accentuation.

Much valuable information can be gained from examination of the peripheral pulses in addition to the status of the arterial system itself. The attentive examiner may observe variations in the rate, rhythmicity, intensity, and contour of the pulse wave that yield insight into a multifariousness of disease states. The rapid, thready pulse of hypovolemic daze is a well-known clinical sign, every bit is the rapid, snapping pulse characteristic of thyrotoxicosis, and the collapsing, "water-hammer" pulse of aortic insufficiency. (Too read Chapter 17, Pulse, and Chapter twenty, Carotid Pulse.)

There are at least iv reasons why it is important to determine if a patient does or does not accept thrombophlebitis. These include the threat and prophylaxis of pulmonary embolism, the chance of septicemia, the use of certain drugs other than anticoagulants, and the occasional detection of whatsoever other primary disease processes.

Deep vein thrombophlebitis requires hospitalization and anticoagulation to prevent morbidity and mortality from associated pulmonary embolism. The efficacy of anticoagulant therapy in this setting was clearly demonstrated in control studies done many years agone. Bear witness is not disarming that anticoagulant therapy is of benefit in phlebitis clearly isolated to superficial veins of the arm or saphenous system of the leg. However, there are communicating leg veins betwixt the superficial and deep venous system, and the examiner bears the responsibleness for determining that the same signs of deep phlebitis are absent.

Pelvic thrombophlebitis and thrombophlebitis associated with indwelling intravenous catheters are a surprisingly frequent source of septicemia. Recognition of either requires careful evaluation of the patient for testify of bloodstream infection.

Thrombophlebitis and pulmonary embolism are more than frequent in recently diuresed patients. Ane should therefore use therapeutic discretion in planning diuretic therapy for patients who belong to any of the previously described "suspicious clinical settings." In add-on, patients receiving corticosteroid therapy are more than susceptible to phlebitis. The same is true for women taking estrogen-containing oral contraceptives; other family planning measures should exist substituted for such therapy in the presence of spontaneous thrombophlebitis.

Thrombophlebitis that is either recurrent, located in unusual veins (subclavian, jugular), or migratory to various superficial veins may be the first sign of an underlying disease procedure such as occult malignancy or systemic lupus erythematosus.

References

1. Coon WW. Venous thromboembolism. Prevalence, risk factors and prevention. Clin Chest Med. 1984;v:391–401. [PubMed: 6386288]

2. Fairburn JK. Juergens JL, Spittell JA. Peripheral vascular diseases. 4th ed. Philadelphia: Westward.B. Saunders, 1972.

3. Homans J. Diseases of the veins. N Engl J Med. 1944;231:51–threescore.

4. Linton RR. Atlas of vascular surgery. Philadelphia: Due west.B. Saunders, 1973.

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Source: https://www.ncbi.nlm.nih.gov/books/NBK350/

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