Patients will typically present acutely with complaints of pain and coolness to touch, and possibly mottling. Chief complaints registered in triage often include the terms “cool foot,” or the more concerning “cold foot.”

The six Ps classically associated with acute limb ischemia include pain, pallor, pulselessness, poikilothermia, paralysis, and paresthesias. However, it should be noted that patients presenting with acute limb ischemia may exhibit any combination of these signs and symptoms, or none at all. During the late stages of presentation, the clinician may note a mottled appearance to the affected leg, difficulty or inability to palpate a dorsalis pedis or posterior tibial pulse, and decreased tactile temperature. Swelling is commonly seen with venous occlusion, but can be seen with arterial occlusion as well.

Blood flow studies are useful when evaluating suspected arterial occlusions, but should not delay expert vascular consultation and expedited restoration of flow. Doppler ultrasound is used to visualize arterial flow or the lack thereof, whereas plethysmography is used to compare blood pressures in the ankles to blood pressures in the arms. Dividing the former by the latter gives a ratio known as the ankle-brachial index, which should be 0.9 or higher to be considered normal.¹ Lab studies, including a blood type and screen, and coagulation assays should also be sent.

Although progressive narrowing of arterial lumina in atherosclerotic disease is typically associated with worsening symptomatic claudication, sudden complete obstruction of lower extremity arterial vasculature represents a surgical emergency, and consultation with a vascular surgeon should be immediately obtained. Vessel bypass grafting, luminal stenting, and peripheral artery thrombolysis are methods used to restore blood flow, and to potentially to save a gravely threatened limb. Heparin administration should also be considered in order to limit the propagation of the thrombus and to protect collateral circulation. Atherectomy is a less commonly used technique for restoration of blood flow to compromised lower extremities.

Vessel bypass grafting involves restoration of blood flow by connecting a portion of the vessel proximal to an occlusion to a portion of the vessel distal to an occlusion. Synthetic vessel materials are often used to bridge across the occluded portion of the vessel.

Vessel stenting involves inserting a tube-like scaffold structure percutaneously into a vessel to ensure adequate flow through the vessel lumen. Stenting is often coupled with balloon angioplasty, to dilate the occluded vessel simultaneously as the stent is deployed.

Peripheral artery thrombolysis involves administration of a fibrinolytic agent near, or directly into, an arterial thrombus. Studies have demonstrated greater efficacy when the agent is delivered into the thrombus, and decreased risk of hemorrhage with intra-arterial over intravenous infusion.²

Atherectomy involves removal of atherosclerotic plaque from blood vessels, typically using catheter devices that cleave the plaque from the endoluminal walls. This technique differs from balloon angioplasty in that the plaque is cut away from the vessel rather than pressed into its walls.

A prior Cochrane systematic review comparing surgery to thrombolysis for the initial management of acute limb ischemia showed neither approach was superior in preventing limb amputation or death within 1 year; however, thrombolysis was associated with a higher risk of ongoing ischemia and of hemorrhagic complications.³

Patients will typically present acutely with complaints of joint pain and swelling, although constitutional symptoms such as fever and malaise may precede focal joint symptoms. Patients who are aware of a diagnosis of RA may repeatedly present for care related to inadequately controlled pain. Episodic flares can prove particularly troublesome for some patients.

RA is characterized by both specific and nonspecific signs and symptoms; examples of the former include symmetric synovial inflammation affecting upper and lower extremity joints, progressive joint destruction, and extra-articular manifestations such as rheumatoid nodules on the skin. Examples of nonspecific signs and symptoms are numerous, and may be difficult to attribute directly to the presence of RA, because many of these same signs and symptoms are vague and identical to those found in many other disease states. Fever, malaise, weakness, and fatigue are examples of nonspecific RA symptoms.

Genetic testing can potentially reveal genes associated with RA. Higher incidence of human leukocyte antigen subsets has been found in RA patients compared to controls.⁶ Autoantibodies such as rheumatoid factor, antinuclear antibodies, and the more specific anti-citrullinated protein antibodies (ACPAs) are also used to detect RA disease, although it is recognized that ACPA negative patients that develop RA may belong to a different RA patient subset. Several newer biomarkers of RA disease are currently being explored.

Radiography is the mainstay of serial surveillance in RA⁷ and is used primarily to assess narrowing of joint spaces, alterations in joint alignment, development of articular surface erosions, and also to reveal fractures and dislocations (Fig. 19-1).

Magnetic resonance imaging allows for greater detail in evaluating joint pathology and earlier detection of disease, but is more time-consuming and costly. Ultrasonography is increasingly used to assess joint effusions, tendons, synovial surfaces, and other structures,⁸ but is limited in that the quality of the images obtained are typically very operator dependent.

Joint aspiration to obtain synovial fluid allows for laboratory assessment to help exclude joint sepsis, as well as crystalline arthritides as the precipitant cause of joint pain and swelling. Often, the white blood cell count level is useful to help distinguish inflammation from infection; a leukocyte count numbering below 50,000 per mL is expected in the former, whereas a cell count greater than 50,000 per mL is expected in the latter. Additionally, Gram stain or synovial fluid culture can further elucidate the infectious source in a suspected septic joint.⁹

Aspiration of joint fluid can also prove therapeutic, as patients will often note symptomatic relief with joint capsule decompression. Strict adherence to aseptic technique must be taken to avoid introducing infection into joint spaces.

Modern approaches to treatment of RA are focused on both symptomatic control and slowing of disease progression. Nonpharmacologic approaches include dietary control, regular exercise, physical therapy, and surgery. A recent Cochrane review examining the effects of dietary manipulation on symptom relief in patients with RA concluded that due primarily to study size limitations, the effects are still uncertain.¹⁰ Pharmacologic therapies include nonsteroidal anti-inflammatory drugs (NSAIDs), oral and injected corticosteroids, disease-modifying antirheumatologic drugs (DMARDs), and immunosuppressive agents. Although the American College of Rheumatology released its updated recommendations for the pharmacologic approach to treating RA,¹¹ most patients would benefit from a treatment regimen that incorporates several pharmacologic and nonpharmacologic approaches.

Patients will typically present complaining of long bone deformity and severe pain, sudden in onset after exposure to minimal force. Patients may report occurrence during an otherwise normal preceding activity, such as jogging, walking, or cutting to change direction while running. Patients with pathologic lower extremity fractures may report suddenly falling down, with subsequent inability to ambulate. Some patients will be unaware of an underlying cancer diagnosis at the time of presentation; therefore, the clinician’s index of suspicion must remain high when caring for patients with long bone fractures who give a history of minimal preceding trauma.

Before presenting acutely with long bone fractures, patients with malignancies metastatic to bone may present with constitutional symptoms common to many cancers, or with symptomatology specific to the given primary cancer. Patients with malignancies metastatic to the long bones of the lower extremities may also note thigh pain, foreleg pain, or pain in one or more joints. Additionally, some patients may exhibit signs and symptoms of hypercalcemia secondary to osteoclast activity.

Radiologic tests can often reveal irregularities consistent with metastatic disease in patients who suffer pathologic fractures, typically demonstrating a fracture line through the abnormal bone. Often noted is cortical thinning, endosteal reabsorption, and cystic-appearing lytic lesions. Plain films will often suffice to reveal the pathologic fracture, whereas advanced imaging, such as computed tomography (CT) or magnetic resonance imaging (MRI), can serve to provide additional details useful in planning fracture fixation (Fig. 19-2).

Radiographic imaging may also suggest to the examiner which or what type of primary malignancy may underlie a pathologic fracture, although a definitive diagnosis requires examination of the affected tissue under a microscope. Assessing for the primary malignancy in patients with pathologic bone fractures often involves laboratory testing aimed at measuring the biomarkers of specific malignant diseases, and other screening tests.

Several primary cancers are commonly associated with bony metastases, with cancers of the breast, prostate, and lung comprising over 80% of the malignancies metastatic to bone.¹³ Abnormal screening tests for any of these cancers in patients who have suffered pathologic long bone fractures can lead to a presumptive cancer diagnosis. Examples of such tests include prostate-specific antigen levels to screen for prostate cancer, mammography or ultrasound to screen for breast cancer, low-dose CT scanning to screen for lung cancer, and urine cytology to screen for kidney cancer.