Limb pain and swelling

Limb pain and swelling are common presentations in both primary and secondary care. Urgent clinical assessment of the acutely painful limb is required to detect traumatic causes (e.g. fractures), acute ischaemia (e.g. arterial thromboembolism, compartment syndrome or massive deep vein thrombosis (DVT)) and life-threatening infections (e.g. necrotizing fasciitis, gas gangrene). Having excluded such ‘surgical emergencies’, medical management includes diagnosis and specific treatment of common causes of acute pain and swelling such as crystal arthritis, septic arthritis or cellulitis (requiring antimicrobial therapy), DVT (requiring anticoagulant therapy) and other common musculoskeletal causes such as Baker’s cyst or muscle haematoma. Ultrasonography plays a key role in differential diagnosis of these conditions. Bilateral swelling of the legs may be due to any of these causes, but commonly results from systemic causes of oedema: heart failure, low serum albumin (e.g. cirrhosis, nephrotic syndrome, malnutrition) or immobility. Outpatient management of stable patients with DVT or cellulitis is increasingly performed by multidisciplinary specialized thrombosis or infection teams, which are based in hospitals with imaging and laboratory support. Intravenous drug users are prone to recurrent DVT and infections, and liaison with community addiction services is important in managing these patients.