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Most acute cases caused by respiratory virus.

• Rest at home including voice rest (best treatment).

• Avoid talking, use voice sparingly (hoarseness lasts 3–14 d).

• Use warm sialogogues (e.g. hot lemon drinks).

• Avoid whispering.

• Drink ample fluids, especially water.

• Avoid smoking and passive smoke.

• Use steam inhalations (5 mins tds).

• Humidity helps, esp. hot steamy showers.

• Use cough suppressants, esp. mucolytic agents.

• Use simple analgesics, e.g. paracetamol or aspirin.

All Australians should have a blood level <10 mcg/dL. Levels above this are associated with adverse nevrocognitive defects.

Children at risk of elevated blood lead:

• aged 9–48 mths living in or visiting older houses with peeling paint

• those with pica

• those living in lead-contaminated areas (e.g. heavy traffic, battery breaking yards)

Symptoms include:

• bad taste in mouth

• lethargy/fatigue

• musculoskeletal aches and pains

• abdominal discomfort

• irritability/abnormal behaviour

• bowel disturbances

Consider lead toxicity in children presenting with developmental delay or behaviour problems and in those with unexplained iron-deficiency anaemia. Active management needed if blood level is >40 mcg/dL (15 g/dL). Treatment involves chelation with Calcium Disodium Edetate, succimer or dimercaprol in hospital. Penicillamine or succimer are oral preparations which can be used.

Spinal causes of leg pain

Problems originating from the spine are an important, yet at times complex, cause of pain in the leg. Important causes are:

• nerve root (radicular) pain from direct pressure, esp. sciatica (L4–S3)

• referred pain from:

  • disc pressure on tissues in front of the spinal cord

  • apophyseal joints

  • sacroiliac joints

• spinal canal stenosis causing claudication

Vascular causes of leg pain

Occlusive arterial disease

Acute lower limb ischaemia

Sudden occlusion whether by embolism or thrombosis is a dramatic event which requires immediate diagnosis and management to save the limb.

Signs and symptoms—the 6 Ps

• Pain

• Pulselessness

• Pallor

• Paralysis

• Paraesthesia or numbness

• ‘Perishing’ cold

Management of acute ischaemia

Golden rules: Occlusion is usually reversible if treated within 4 h (i.e. limb salvage). It is often irreversible if treated after 6 h (i.e. limb amputation).

Treatment

• Intravenous heparin (immediately) 5000 U

• Emergency embolectomy (ideally within 4 h) or

• Arterial bypass if acute thrombosis in chronically diseased artery or

• Stenting of vessels (a modern option)

• Amputation (early) if irreversible ischaemic changes

Lifelong anticoagulation with warfarin will be needed.

Chronic lower limb ischaemia

Chronic ischaemia caused by gradual arterial occlusion can manifest as intermittent claudication or rest pain in the foot.

Treatment

• General measures (if applicable): control obesity, diabetes, hypertension, hyperlipidaemia, cardiac failure.

• Achieve ideal weight.

• Absolutely no smoking (the risk factor).

• Exercise: daily graduated exercise to the level of pain. Approx. 50% will improve with walking so advise as much walking as possible.

• Try to keep legs warm and dry.

• Maintain optimal foot care (podiatry).

• Drug therapy: aspirin 150 mg daily.

Note: Vasodilators and sympathectomy are of little value. ∼1/3 progress, while the rest regress or don't change.

When to refer to a vascular surgeon

• ‘Unstable’ claudication of recent onset; deteriorating

• Severe claudication—unable to maintain lifestyle

• Rest pain

• ‘Tissue loss’ in feet (e.g. heel cracks, ulcers on or between toes, dry gangrenous patches, infection)

Venous disorders

Varicose veins

Varicose veins and pain

They may be painless even if large and tortuous. Pain is a feature where there are incompetent perforating veins running from the posterior tibial vein to the surface through the soleus muscle.

Severe cases lead to the lower leg venous hypertension syndrome characterised by pain worse after standing, cramps in the leg at night, irritation and pigmentation of the skin, swelling of the ankles and loss of skin features such as hair.

Prevention

• Maintain ideal weight.

• High-fibre diet.

• Rest and wear supportive stockings if at risk (pregnancy, a standing occupation).

Treatment

• Keep off legs as much as possible.

• Sit with legs on a footstool.

• Use supportive stockings or tights (apply in morning before standing out of bed).

• Avoid scratching itching skin over veins.

Compression sclerotherapy

• Use a small volume of sclerosant (e.g. 5% ethanolamine oleate; STD).

• Ideal for smaller isolated veins.

Surgical ligation and stripping

• The best treatment when a clear association exists between symptoms and obvious varicose veins (i.e. long saphenous vein incompetence).

• Remove obvious varicosities and ligate perforators.

Superficial thrombophlebitis

Treatment

The objective is to prevent propagation of the thrombus by uniform pressure over the vein.

• Cover whole tender cord with a thin foam pad.

• Apply a firm elastic bandage (preferable to crepe) from foot to thigh (well above cord).

• Leave pad and bandage on for 7–10 d.

• Bed rest with leg elevated is recommended.

• Prescribe an NSAID esp. if a complication of IV infusion (e.g. indomethacin or diclofenac (ο) 75 mg bd) or diclofenac 1% gel topically tds for 14 d.

Note:

• If spontaneous, consider an LMWH SC daily for 4 wks.

• If the problem is above the knee, ligation of the vein at the saphenofemoral junction may be necessary.

Deep venous thrombosis (DVT)

DVT may be asymptomatic but usually causes tenderness in the calf. One or more of the following features may be present (refer to Wells’ diagnostic algorithm: www.mdcalc.com wells-criteria-for-dvt).

Clinical features

• Ache or tightness in calf

• Acute diffuse leg swelling

• Pitting oedema

• Tender ‘doughy’ consistency to palpation

• Increased warmth (may be low-grade fever)

• Pain on extension of foot

• Tenderness (gently squeeze calves)

Predisposing conditions:

• thrombophilia

• thrombocytosis (↑ platelets)

• polycythaemia rubra vera

Investigations

• Duplex US: accurate for above-knee thrombosis; improving for distal calf (repeat in 1 wk if initial test normal)

• Contrast venography, esp. if ultrasound −ve

• MRI is very accurate

• D dimer test (consider in certain cases): where probability of DVT is low, a normal D dimer usu. excludes diagnosis

• Coagulation disorder screen ?thrombophilia

Management

Prevention (cases at risk):

• early and frequent mobilisation/exercises

• elastic or graded compression stockings

• physiotherapy

• pneumatic compression

• electrical calf muscle stimulation during surgery

• surgery: unfractionated heparin 5000 U (SC) bd or tds (LMW heparin for orthopaedic surgery)

• long flights/sitting: LMWH prior to flying and on arrival

Treatment

• Admit to hospital (usu. 5–7 days) but can treat as an outpatient.

• Collect blood for APTT, INR and platelet count (check kidney function).

• One-way-stretch elastic bandages (both legs to above knees) or class II graded compression stocking to affected leg, esp. if swelling

• LMW heparin e.g. enoxaparin SC daily or

  Unfractionated heparin 330 U/kg, SC loading then 250 U/kg SC bd or

  5000 U statim bolus IV then infusion in IV saline or

  Fondaparinux SC according to weight

• Oral anticoagulant (warfarin) for 6 mths (monitor with INR)

• Mobilisation upon resolution of pain, tenderness and swelling

Surgery is necessary in extensive and embolising cases.

Cellulitis and erysipelas of legs

• Rest in bed

• Elevate limb (in and out of bed)

• Aspirin for pain and fever

• Search for evidence of diabetes

Treatment

Streptococcus pyogenes (the common cause):

• Severe: di (flu)cloxacillin (child: 50 mg/kg up to) 2 g IV, 6 hrly

• Less severe: procaine penicillin 1 g IM 12 hrly or phenoxymethyl penicillin 500 mg (o) 6 hrly

• If penicillin sensitive: clindomycin 450 mg (o) 8 hrly

Staphylococcus aureus:

• Severe, may be life-threatening: di(flu)cloxacillin 2 g IV 6 hrly

• Less severe: di(flu)cloxacillin 500 mg (o) 6 hrly or cephalexin 500 mg (o) 6 hrly if penicillin sensitive

Osteomyelitis and septic arthritis

Sepsis may occur in major joints such as the hip and knee. Osteomyelitis usually occurs in long bones, e.g. the tibia. Presents with pain, fever, malaise and unwillingness to move the affected part. The primary site, such as a wound or skin abscess, is often not found. Perform joint aspiration and blood culture + imaging. Oganisms—S. aureus, E. coli, Kingella, Pseudomonas, others. Usually treated with IV di(flu)cloxacillin.

Nocturnal cramps

Head lice

Treatment

• Pyrethrins 0.165% with piperonyl butoxide 2% (e.g. Lyban) foam or shampoo or

• Permethrin 1% or Maldison 1%

Method

• Massage well into wet hair.

• Leave for a minimum of 20 minutes except maldison—leave 8 h (usu. overnight).

• Wash off thoroughly (avoid eye contact).

• Comb with a fine–toothed comb.

• Repeat after 7 d and comb.

Note:

• The hair does not have to be cut short.

• Treat all household child contacts if lice or nits found on inspection.

• Wash clothing and bedclothes after treatment (normal machine wash).

• If resistant, use Permethrin + Cotrimoxazole (o) for 10 d.

Eyelash involvement

• Apply petrolatum (Vaseline) bd for 8 d, then pluck off remaining nits.

Handy tips for removal of nits

• Use a hair conditioner on dry hair, comb with a fine-toothed comb.

• Apply a 1:1 mixture or water and vinegar, leave 15 mins then comb.

Pubic lice

Can use same topical agents as for head lice.

Method

• Apply to pubic hair.

• Leave for a time according to manufacturer's instructions (e.g. 10 mins for Lyban and Permethrin 1%, 12 h for Maldison).

• Wash off thoroughly.

• Wash underwear and bedclothes after treatment.

• Repeat after 7 d (maybe third treatment).

• Treat sexual partners.

Lichen planus is a disorder of unknown aetiology characterised by pruritic violaceous flat-tipped papules, mainly on the wrists and legs.

Clinical features

• Young and middle-aged adults

• 4 Ps—papule, purple, polygonal, pruritic

• Small, shiny, lichenified plaques

• Symmetrical and flat-tipped

• Flexor surfaces: wrists, forearms, groin, ankles

• Can affect oral mucosa—white streaks or papules or ulcers

• Can affect nails and scalp

Management

• Explanation and reassurance

• Usually resolves over months, leaving discoloured marks without scarring

• Recurrence rare

• Asymptomatic lesions require no treatment

• If symptomatic (e.g. itching):

  • topical moderate to very potent fluorinated steroids under plastic occlusion

  • intralesional corticosteroids for hypertrophic lesions

• Oral prednisolone if not successful