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5 DD. ofSwelling intheFemoral Triangle
35
Present History
• Onset: catastrophic onset “in traumatic femoral aneurysm or A.V stula called
Bucher’s thigh”, Acute such as acute Lymphadenopathy, Subacute such as
chronic lymphadenopathy or insidious or accidentally discovered “such as
Saphena Varix and neuromas”
• Course: Rapidly progressive such as acute inammatory LNs, rapidly progres-
sive “Such as metastatic Lymph nodes from carcinoma of the Anal canal or Vulva
or Lymphoma” very slowly progressive or stationary “such as Lipoma”
• Duration: long duration usually indicates benign lesions.
• Limb distal: For pulses, Veins, Lymphatic edema, sensation and motor power
“Active and passive”.
• Perineum: For primary tumor or inammation.
• Abdominal and Pelvic Symptoms: For other hernias in case of hernias, other
arterial diseases or aneurysms, other lymph node enlargements and/or
hepatosplenomegaly.
• Other swellings in the body: for other aneurysms or associated ischemias in the
other parts of the body in cases of femoral aneurysm or for Generalized lymphadenopathy in cases of Inguino-iliac lymphadenopathy or for COPD as a cause
of increased intra-abdominal pressure as a cause for an inguinal or femoral hernia.
Personal History
• Age is important to differentiate between the etiologies of P.A. aneurysm due to
arteritis and atherosclerosis “Old age”. Ectopic testis usually in infancy,
Childhood or in young males. Inguinal Lymphadenopathy due to malignant
lesions is most probably is due to Lymphoma in young age or due to Secondaries
from a Lower Limb Melanoma or SCC or from Pelvic malignancy in older
age group.
• Sex: Femoral Hernia is more common in females but it can occur in males.
• Occupation: Saphena Varix due to Varicose veins are more common among
teachers, Surgeons and Sellers.
• Habits of Medical importance: Such as smoking in aneurysms.
• Contraceptive pills: Are contraindication to use injection sclerotherapy to treat
Varicose veins for dear of spreading thrombosis into the deep system of veins.
• Complaint:
• Swelling in the Femoral triangle “Upper part of the front of the thigh”
which may be:
• Painless.
• Painful:
36
A. Farag
1. In acute or associated with pain such Acute Lymphadenitis, complicated
Femoral Hernia,
2. Pain not related to the swelling may be:
– Due to Varicose Veins in cases of affected long saphenous System.
– Acute Ilio-Femoral Thrombosis.
– Due to distal ischemia associated with Femoral artery aneurysm.
– Due to Nerve pain in cases of Neurobrosarcoma of the Femoral nerve
affecting mainly the front of the thigh “Distribution of the femoral nerve”.
– Due to a primary inammatory or painful malignant lesion in the limb
distally metastasizing into the Vertical group of the supercial
inguinal LNs.
– Bone pain from Primary or secondary bone tumor with or without
pathologic fracture.
– Acute inammation in the skin or subcutaneous tissue.
Present History
• Onset:
1. Trauma?
2. Inammation?
3. Mode of Onset?
– Immediate in Bucher’s thigh, Strangulated Hernia or pathologic fracture
of the upper end of the femur.
– Acute “Hours” in Acute abscess, Cellulitis or Acute Lymphadenitis.
– Gradual or accidentally identied in the rest of swellings.
• Course:
• Progressive “Rapid or Slow progression”. Rapidly progressive like expanding
hematoma after traumatic femoral artery Aneurysm. Or Slowly progressive
“over Hours or days” like acute inammatory lesions.
• Regressive “spontaneous or on treatment such as in cases of inammation”.
• Duration: Very short “Rupture aneurysm or traumatic A-V stula or Femoral
hernia complicated by obstruction or strangulation”, short “Inammation”
Weeks, months or years in the rest of pathologies”
• Associated Symptoms:
• Of a primary focus “Neoplastic or inammatory in the ipsilateral LL or in the
Pelvis or perineum.
• Acute Limitation of the movement of the hip joint “with exion” due to an
Ileopsoas abscess or in acute appendicitis with retrocaecal Position.
5 DD. ofSwelling intheFemoral Triangle
• Distal LL edema in cases of Varicose veins with skin pigmentation and ulcer-
ations in secondary varicose veins.
• Claudication pains or rest pain if PA aneurysm is associated with distal arte-
rial disease or Blue toe Syndrome from repeated distal embolization in cases
of mural thrombosis in PA aneurysm.
• Acute distal critical ischemia “Pain, Pallor, pulseless distal limb with acute
loss of function which may show later mottling, Cyanosis and acute gangrene
from acute thrombosis of a Femoral artery aneurysm” with edema in cases of
acute rupture of PAA.
• Multiple similar Swellings in the same limb “Popliteal LN” in cases of inam-
matory or neoplastic “Secondaries from squamous cell carcinoma or
Melanoma “Black colored LNs with or without in-transit black metastases at
the medial aspect of the thigh Lymphatics” or primary neoplastic cause such
as Lymphoma or Leukemia”
• Multiple lipomas.
• Boney swellings like exostosis or metastases.
• Systemic manifestations of inammations, other Lymph node affection,
Hepatosplenomegaly in cases of Lymphoma/Leukemia, Systemic allergies
autoimmune diseases, Neurobromatosis with Café-au-Lait patches, Allergies
including Urticaria, scratch marks, serum Sickness or metastases to the Lung,
Liver, brain or bones or the source of metastases in the upper end of the femur
like breast cancer.
37
Past History
• Medical for Similar disease in other LL or other parts of the body and treatments
that may disclose some diseases forgotten by the patient specially in the rst
medical visit not recorded in the le or the patient is trying to hide like TB, HIV,
Syphilis “though rare” Sexually transmitted disease.
• Allergies.
Family History
Of Similar disease and other diseases of medical importance.
General Examination
As in the general sheet is very important to for 3 reasons:
38
A. Farag
• General assessment of the patient which may uncover another serious or gen-
eral disease which should be taken in consideration while requesting investigations and/or during planning for treatment of the patients such as associated
vital organ dysfunction or failure “Cardiac, respiratory, Liver, Kidney”.
• May uncover the stage of the disease in cases of Lymphoma and Malignant
tumors such as node metastases from SCC or Melanoma or in cases of osteosarcoma and Ewing’s tumor in the liver, lung, brain or other sites.
• May be the only clue for diagnosis of the mass in the Popliteal fossa as in:
• Systemic inammation “Fever and rigors in cases of Acute Cellulitis/
abscess or acute lymphadenitis.
• Similar tumor “DD of multiple tumors” due to Pyaemic abscesses, multiple papillomas, sebaceous cysts, Lipomas or Lipomatosis if painful it is
Dercum’s disease, Multiple Exostosis, Generalized Lymphadenopathy,
Multiple neurobromatosis “associated with cafe-au-lait patches
• Aneurysms or ischemias affecting other site of the body “Peripheral, CVS,
Intestinal or Renal”.
Local Examination
Swelling:
• Inspection: Position, Gait, Color, Contour, Localized swelling, trophic
changes, dilated Tortious veins “Varicose Veins VV”, Ulcerations, Masses.
Gangrene.
• Palpation: Temperature, Tenderness, Site, Size, shape, Surface, Edge,
Consistency, Mobility, Surrounding structures, Other Swellings.
• Special signs: Pulsations “Expansile or transmitted” Trans-illumination test
• Percussion: Resonant in case of femoral hernia containing bowel “not common”
• Auscultation: Bruit “Aneurysm or Machinery Murmur “Traumatic A.V. stula”.
Limb distal: for:
• Pressure effects on veins, nerves, or associated Ischemia.
• For a primary malignant Lesion “Carcinoma or Melanoma” or for a primary
inammatory lesion.
Limb Proximal: for:
• Other Similar masses.
• Arteries, Veins and Nerves.
• Associated affected inammatory or Malignant Lymph node in the Inguinoiliac Group of LNs “The Vertical croup of the supercial inguinal LNs and the
Internal iliac group are draining the LL, While the transverse group are draining the Perineum, Anal canal and Vagina into the medial half and the buttocks
5 DD. ofSwelling intheFemoral Triangle
and back below a line at the Level of the Umbilicus is draining into its
Lateral Half”.
Other Lower Limb: for:
• Comparison.
• A similar “Bilateral condition”.
Abdominal examination:
For:
• Lymphadenopathy.
• Hepatosplenomegaly in cases of Lymphoma/Leukemia or Liver mets in cases
of Melanoma, Osteosarcoma or other malignant tumors in the LL or in the
popliteal fossa.
• Abdominal Aortic or Iliac artery aneurysms.
• Other masses such as retroperitoneal Sarcoma.
• The cause of an Ileopsoas abscess “TB spine or Crohn’s d”.
39
Chapter 6
Swelling inthePopliteal Fossa
AhmedFarag
Abstract Anatomical background:
Boundaries:
1. The Biceps Femoris tendon (superolateral).
2. Semimembranosus reinforced by Semitendinosus (superomedial).
3. The medial and lateral heads of Gastrocnemius form the inferomedial and inferolateral boundaries, respectively.
4. Floor is made by the back of the knee Joint, Lower part of the Femur or upper
part of the Tibia.
5. The Roof made by the skin and subcutaneous tissue.
Keywords Popliteal · Fossa · Mass · Examination · Anatomy · Pathology ·
Boundaries · Content
Anatomical Background
• Boundaries:
1. The Biceps Femoris tendon (superolateral).
2. Semimembranosus reinforced by Semitendinosus (superomedial).
3. The medial and lateral heads of Gastrocnemius form the inferomedial and
inferolateral boundaries, respectively.
4. Floor is made by the back of the knee Joint, Lower part of the Femur or upper
part of the Tibia.
5. The Roof made by the skin and subcutaneous tissue.
• Contents:
1. Popliteal artery.
A. Farag (*)
Kasr Alainy Hospital, Cairo University, Cairo, Egypt
Switzerland AG 2024
A. Farag et al. (eds.), Clinical Surgical Skills Made Easy,
https://doi.org/10.1007/978-3-031-69158-4_6
41© The Author(s), under exclusive license to Springer Nature
42
2. Popliteal vein.
3. Tibial nerve.
4. Common peroneal nerve.
5. Short Saphenous vein and Sapheno-femoral Junction.
6. Popliteal LN.
Popliteal fossa Swelling is part of the Sheet of examination of A Swelling including
general and local examination, examination of a Limb namely examination of the
Limb distal and Limb Proximal “See related chapter” and Areas to be examined
namely both LLs, Abdomen and minimum the Virchow LN in a short as OSPE sheet
“in the General examination sheet” in our daily practice it is always recommended
to do a thorough though swift general examination as the clue for diagnosis may be
in the General examination e.g. other aneurysms, LNs or metastases from the lesion.
Or it may disclose another disease of importance like Heart failure, arrhythmias,
Liver failure ….etc.
A. Farag
DD ofaMass inthePopliteal Fossa
1. Semimembranosus Bursa: From the ST tendon.
2. Baker’s Cyst: Herniation of the Synovial Fluid through a defect in the capsule of
the knee joint associated with Osteoarthritis.
3. Varicose veins: affecting the short Saphenous vein with incompetent Saphenopopliteal Junction.
4. Popliteal artery aneurysm: from the P.A.
5. Neurobroma: from the Tibial or Common Peroneal nerve.
6. Sebaceous cyst, abscess, Cellulitis, Lipomas …etc. from the skin and subcutaneous tissue.
7. Boney swelling: from the Lower end of the Femur or upper end of the tibia:
Exostosis, benign tumors such as cysts, benign Osteoma or Chondroma or
Malignant tumors such as Osteosarcoma and Ewing’s tumor.
8. Acute Swelling: Rupture P.A. Aneurysm, Ruptured Baker’s cyst or
Semimembranosus bursa or a subcutaneous cellulitis/abscess or Acute Popliteal
Lymphadenitis “Less Common”
Personal History
• Age is important to differentiate between the Baker’s cyst “Old age” and
Semimembranosus bursa “Younger” and between the etiologies of P.A. aneurysm due to arteritis and atherosclerosis “Old age”.
• Occupation: Varicose veins are more common among teachers, Surgeons and
Sellers.
6 Swelling inthePopliteal Fossa
43
• Habits of Medical importance: Such as smoking in aneurysms.
• Contraceptive pills; Are contraindication to use injection sclerotherapy to treat
Varicose veins for dear of spreading thrombosis into the deep system of veins.
• Complaint:
• Swelling in the back of the knee which may be:
• Painless.
• Painful:
1. In acute or associated with pain such as Baker’s Cyst which is associate
with Osteo arthritis.
2. Pain not related to the swelling may be:
– Due to Varicose Veins in cases of affected Short saphenous System.
– Due to distal ischemia associated with P.A. aneurysm
– Due to Nerve pain in cases of Neurobrosarcoma.
– Due to a primary inammatory or painful malignant lesion in the limb
distally metastasizing into the Popliteal LN.
– Pain may be in the proximal LNs at the Groin affected by the pathology
in the Popliteal fossa or the limb distally.
Present History
• Onset:
1. Trauma?
2. Inammation?
3. Mode of Onset?
• Immediate in Ruptured Baker’s Cyst or ruptured P.A.Aneurysm.
• Acute “Hours” in Acute abscess, Cellulitis or Acute Popliteal LN.
• Gradual or accidentally identied in the rest of swellings.
• Course: Progressive “Rapid or Slow progression”, Regressive “spontaneous or
on treatment such as in cases of inammation”.
• Duration: Very short “Rupture PPA or Baker’s cyst”, short “Inammation”
Weeks, months or years in the rest of pathologies”
• Associated Symptoms:
• Osteoarthritis in Baker’s Cyst but absent in Semimembranosus bursa.
• Acute Limitation of the movement of the knee in Acute situation “Rupture PA
Aneurysm or SM Bursa and in acute inammation” associated with fever and
rigors in the acute cellulitis abscess or acute Lymphadenitis.
• Distal edema in cases of Varicose veins with skin pigmentation and ulcerations in secondary varicose veins.
44
• Claudication pains if PA aneurysm is associated with distal arterial disease or
Blue toe Syndrome from repeated distal embolization in cases of mural
thrombosis in PA aneurysm.
• Acute distal critical ischemia “Pain, Pallor, pulseless distal limb with acute
loss of function which may show later mottling, Cyanosis and acute wet gangrene from simultaneous compression on the Popliteal vein” with edema in
cases of acute rupture of PAA.
• Multiple similar Swellings in the same limb “Groin” incases of inammatory
or neoplastic “Secondaries from squamous cell carcinoma or primary neoplastic cause such as Lymphoma or Leukemia” enlargement of the
Popliteal LN.
• Multiple lipomas.
• Boney swellings like exostosis or metastases.
A. Farag
Past History
• Medical for Similar disease in other LL or other parts of the body and treatments
that may disclose some diseases forgotten by the patient specially in the rst
medical visit not recorded in the le or the patient is trying to hide like TB, HIV,
Syphilis “though rare” Sexually transmitted disease.
• Allergies.
Family History
Of Similar disease and other diseases of medical importance.
General Examination
As in the general sheet is very important to for 3 reasons:
• General assessment of the patient which may uncover another serious or gen-
eral disease which should be taken in consideration while requesting investigations and/or during planning for treatment of the patients such as associated
vital organ dysfunction or failure “Cardiac, respiratory, Liver, Kidney”.
• May uncover the stage of the disease in cases of Lymphoma and Malignant
tumors such as popliteal node metastases from SCC or Melanoma or in cases
of osteosarcoma and Ewing’s tumor in the liver, lung, brain or other sites.
• May be the only clue for diagnosis of the mass in the Popliteal fossa as in:
6 Swelling inthePopliteal Fossa
• Systemic inammation “Fever and rigors in cases of Acute Cellulitis/
abscess or acute lymphadenitis.
• Similar tumor “DD of multiple tumors” due to Pyaemic abscesses, multiple papillomas, sebaceous cysts, Lipomas or Lipomatosis if painful it is
Dercum’s disease, Multiple Exostosis, Generalized Lymphadenopathy,
Multiple neurobromatosis “associated with cafe-au-lait patches.
• Aneurysms or ischemias affecting other site of the body “Peripheral, CVS,
Intestinal or Renal”.
Local Examination
Swelling:
• Inspection: Position, Gait, Color, Contour, Localized swelling, trophic
changes, dilated Tortious veins “Varicose Veins VV”, Ulcerations, Masses.
Gangrene.
• Palpation: Temperature, Tenderness, Site, Size, shape, Surface, Edge,
Consistency, Mobility, Surrounding structures, Other Swellings.
• Special signs: Pulsations “Expansile or transmitted” Trans-illumination test
• Percussion: Not applicable here.
• Auscultation: Bruit “Aneurysm or Machinery Murmur “Traumatic A.V. stula”.
45
• Semimembranosus Bursa: Cystic “Positive uctuation test in two direc-
tions”, Translucent swelling in the medial aspect of the popliteal fossa at
the lateral aspect of the semi- membranous tendon which increases in size
during extension and deceases in size or disappears during exion. It happens in young patients with normal knee joint.
• DD. Baker’s cyst which occurs as herniation of the Synovial membrane in
older patients with osteoarthritis. The important point in clinical DD is that
removal of the Bakers cyst is not recommended because the cause of pain
is due to osteoarthritis.
• Popliteal Lymphadenopathy: A well-dened rounded tender hot mass if
draining an acute septic focus in the heel or back of the leg.
• Varicose veins affecting the short saphenous system and Incompetent
Sapheno-popliteal Junction: soft, cystic, compressible and Blush swelling
which is tortuous and shows incompetent saphenofemoral Junction on
Multiple Tourniquet test. “See Venous sheet”
• Neurobroma or neurobromatosis of the Tibial nerve “In the Middle of
the fossa” or Common Peroneal nerve “at the lateral aspect of the Fossa”:
Oblong in shape in the line of the nerve which can be moved side to side
but not vertically, rm in consistency may show tenderness which may
radiate as tingling or pain distally on palpation. It may be a part of
neurobromatosis.