Ref: Varicose Veins Exam

1. General considerations
2. History
3. Inspection
4. Palpation
5. Cough impulse test
6. Trendelenberg test
7. Perthes' test

General considerations

• 2 sets of veins, deep and superficial. "Deep veins" means deep to the fascia.
• Flow is superficial veins to deep veins.
• Arise by: calf pumps up, pushing blood out into superficial veins. Superficial veins then dilate, spreading their own valves apart, so the superficial veins become torturous.
• Walking with a pressure tourniquet on leg
  • If competent valves, gets better as walk.
  • If incompetent valves between deep and superficial, no effect.
  • If DVT, gets more painful as walk [since exit is blocked]. 
• Can optionally use a Doppler after physical examination.
• Management: graduated compression stockings or surgery.
• Surgery complications: infection from groin crease, hematoma from strip, scarring, recurrence.

History

• Pain.
• Possibly hemorrhage or thrombophlebitis.
• Ask about prior varicose operations and results.

Inspection

• Pt stands, both legs completely visible.
• Looking for "dilated, tortuous veins that you will examine for site of incompetency".
• Inspect from anterior of thighs to lateral of legs (long saphenous vein).
• Inspect back of calves (short saphenous vein).
• Look for poor skin nutrition:
  • Venous ulcers, esp on medial malleolus. See Ulcers examination.
  • Venous eczema.
  • Hemosiderin deposition [brown].
  • Thin skin.
• DDx from femoral hernia, since varicose veins:
  • Are blue.
  • Disappear when lie flat.
  • Show a positive cough impulse.

Palpation

• Tenderness (thrombophlebitis).
• Hard (thrombosis).
• Skin:
  • Dermatosclerosis [thick, indurated skin].
  • Atrophie blanche [scarred, white skin].

Cough impulse test

• Pt stands.
• Dr's fingers held over saphenofemoral opening [5 cm below and medial to femoral pulse].
• Pt. coughs.
• If saphenofemoral incompetent, cough makes a fluid thrill.

Trendelenberg test

• Purpose is to find how far up the leg the imcompetent valves are.
• Pt lies flat, leg is elevated.
• Tie tourniquet around thigh at saphenous opening [5 cm below and medial to femoral pulse] .
• If Dr doen't have a tourniquet, use 2 fingers instead.
• Pt stands.
• If normal valve at tourniquet site, will see blood slow filling from below tourniquet.
• Take off tourniquet: if a incompetent valve there, will have a sudden gush filling from above when remove tourniquet.
• Can repeat procedure down the leg, until find the incompetent valve.
• Note: there's a different Trendelenberg test for proximal myopathy of hip.

Perthes' test

• Similar to Trendelenberg test.
• Release a bit of tourniquet, but pt raises up and down on toes after releasing.
• If perforating calf veins have competent valves, calf pump will function, making varicosities less tense.