Swollen extremity
Swollen extremity is a common ED presentation requiring evaluation for dangerous vascular, infectious, and musculoskeletal causes.
Differential Diagnosis
Unilateral Upper or Lower Extremity
- Deep venous thrombosis
- Cellulitis / soft tissue infection
- Abscess
- Compartment syndrome
- Fracture
- Septic arthritis
- Baker cyst rupture (posterior knee)
- Lymphedema (post-surgical, radiation)
- Venous insufficiency
- Post-thrombotic syndrome
Bilateral Lower Extremity
- Congestive heart failure
- Venous insufficiency (chronic)
- Nephrotic syndrome
- Cirrhosis
- Medication-related (CCBs, NSAIDs)
- Hypothyroidism
- Preeclampsia (in pregnancy)
With Pain and Erythema
- Cellulitis
- Necrotizing fasciitis - surgical emergency
- Gout / Pseudogout
- Septic arthritis
- DVT
- Compartment syndrome
Evaluation
- Assess for red flags: pain out of proportion, crepitus, rapidly spreading, hemodynamic instability
- Compare to contralateral extremity
- Unilateral leg swelling: apply Wells criteria, obtain D-dimer or compression ultrasound
- If infection suspected: CBC, BMP, lactate, blood cultures if septic
- Compartment pressures if compartment syndrome suspected
- Joint aspiration if septic arthritis on differential
- X-ray if fracture suspected
Management
- DVT: Anticoagulation per protocol
- Cellulitis: Antibiotics (see Skin and soft tissue antibiotics)
- Necrotizing fasciitis: emergent surgical consultation, broad-spectrum antibiotics
- Compartment syndrome: emergent fasciotomy
- Heart failure: Furosemide, treat underlying cause
Disposition
- Admit for necrotizing fasciitis, compartment syndrome, septic arthritis, or sepsis
- Admit for severe cellulitis requiring IV antibiotics
- Consider admission for proximal DVT in high-risk patients
- Discharge with close follow-up for uncomplicated DVT on anticoagulation
- Discharge with PCP follow-up for bilateral edema with stable vitals