Expansion
Examine standing, then locate the site of reflux
Expansion
Look, standing
- Distribution: long saphenous on the medial calf and thigh, short saphenous on the posterior calf, or non-saphenous
- Skin changes of chronic venous insufficiency: haemosiderin pigmentation, varicose eczema, lipodermatosclerosis with the inverted champagne bottle leg, atrophie blanche, and ulceration in the gaiter area
- Oedema, scars from previous surgery
Feel: tenderness (thrombophlebitis), hardness, a saphena varix at the groin which has a cough impulse and disappears on lying down, and a palpable fascial defect at a perforator.
Tests of incompetence
- Cough impulse at the saphenofemoral junction
- Tap test: tap distally and feel proximally; transmission indicates an incompetent column between
- Trendelenburg test: elevate the leg to empty the veins, apply pressure over the saphenofemoral junction, then stand the patient. If the veins stay empty, the incompetence is at the junction. If they refill, there is incompetence below, from perforators
- Tourniquet test, repeating at successive levels to localise
- Perthes test for deep venous patency
Handheld Doppler and, in practice, duplex ultrasound have superseded these tests, and duplex is mandatory before any intervention. The clinical tests remain valuable as an examination framework and for understanding what duplex is looking for.
Complete by examining the abdomen and pelvis for a mass, and the arterial pulses, since compression is contraindicated in arterial disease.