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Home , Erythromelalgia

SPECIAL COMMUNICATION

Buerger Test for Erythromelalgia Revisited William F. Wright, DO, MPH Manu Rajachandran, MD

From the Division of Leo Buerger, MD, was the first to describe dependent rubor associated Infectious Diseases with marked . Historically, dependent rubor has been de- (Dr Wright) and the Division of scribed as erythromelalgia (or erythromelia), and terms such as chronic (Dr Rajachandran) in the rubor, reactionary rubor, induced rubor, and hyperemic response have Department of Medicine at also been used to describe this sign associated with peripheral vascular Memorial Medical Center in York, Pennyslvania. disease. This brief review will reacquaint physicians with the Buerger test,

Financial Disclosures: which is used to assess arterial sufficiency, as well as erythromelalgia, and None reported. the proposed mechanisms responsible for erythromelalgia. The Buerger

Support: None reported. test is an important consideration when examining patients for erythro-

Address correspondence to melalgia, which remains distinct from associated with and William F. Wright, DO, MPH, soft-tissue infections. Division of Infectious Diseases, J Am Osteopath Assoc. 2017;117(2):124-126 Department of Medicine, doi:10.7556/jaoa.2017.023 Memorial Medical Center, 1600 6th Ave, Ste 114, Keywords: Buerger test, dependent rubor, erythromelalgia, rubor York, PA 17403-2643.

E-mail: [email protected] n this 1924 publication, The Circulatory Disturbances of the Extremities: Including Submitted Gangrene, Vasomotor and Trophic Disorders,1 Leo Buerger, MD, was the first to de- June 15, 2016; scribe dependent rubor associated with marked atherosclerosis.2,3 Buerger introduced revision received I August 1, 2016; accepted several new physical signs for vascular conditions, including gangrene and peripheral September 8, 2016. .1,3 Buerger emphasized the importance of recognizing potential symptoms associated with chronic atherosclerosis before gangrene is apparent, such as absent pulses, extremity coldness, foot and toe ulcers, impaired nail growth, poor refill, foot pallor with limb elevation, and redness of the limb in the dependent position.1,3 Rubor involving the toes, sometimes the dorsal (Figure 1) and plantar (Figure 2) aspects of the foot at varying distances on a limb (to the ankle or higher) in the dependent or hori- zontal position, is a phenomenon Buerger termed erythromelalgia (Greek. erythrós, red; melia, limb).1,3 Terms such as dependent rubor, chronic rubor, reactionary rubor, induced rubor, and hyperemic response have also been used to describe erythromelalgia (or eryth- romelia).1,3 Although Buerger stated that erythromelalgia was most characteristic of throm- boangiitis obliterans, it was also found with marked atherosclerotic occlusions of larger in patients with or without diabetes mellitus.1 Physicians should be aware that erythromelalgia is a sign of clinically significant pe- ripheral vascular disease and is independent of skin and soft-tissue infections. The purpose of this brief review is to reacquaint physicians with the Buerger test (which is used to assess arterial sufficiency), erythromelalgia, and the proposed mechanisms responsible for eryth- romelalgia, and also to describe the evidence-based foundation for their clinical reliability.

124 The Journal of the American Osteopathic Association February 2017 | Vol 117 | No. 2 SPECIAL COMMUNICATION

Pathophysiologic Process A B Buerger stated that erythromelalgia is caused by a compensatory dilatation of superficial re- sulting from substantial luminal narrowing of larger arteries.1 In a prospective single-center trial, Schwartz et al4 used noninvasive video microscopy to document qualitative morphologic characteristics of lower-ex- tremity nutritional skin microcirculation in patients with atherosclerosis. Fourteen study participants with artherosclerosis and 11 age-matched control partici- pants were assessed for capillary blood flow velocity, capillary diameter, and number of flow-active capil- laries. The study participants were found to have a capillary blood flow velocity of 0.16 mm/s, capillary Figure 1. diameter of 10.5 µm, and 6.8 capillaries per field, Erythromelalgia, or dependent rubor, with the dorsal foot in the dependent position (A) or at 60º in the horizontal whereas the control participants had a capillary blood position for 2 minutes (B). flow velocity of 0.10 mm/s, capillary diameter of 8.7 µm, and 5.3 capillaries per field. These data support A B erythromelalgia as the clinical manifestation of a com- pensatory dilatation of superficial capillaries and of an increased number of flow-active capillaries.

The Buerger Test Placement of the healthy foot in the dependent posi- tion below heart level decreases capillary blood flow, and elevation produces no changes in flow.4 However, the same maneuver in patients with foot pain at rest and clinically significant atherosclerosis results in in- creased capillary blood flow with pedal dependency (ie, the patient is seated on an examination table with Figure 2. the foot in the down position) and decreased capillary Erythromelalgia, or dependent rubor, with the plantar foot blood flow on pedal elevation.4 The Buerger test in the dependent position (A) or at 60º in the horizontal position for 2 minutes (B). should be used to evaluate patients suspected of having reduced circulation due to vascular obtura- tion.1 When administering this test, physicians should color returns (ie, the angle of circulatory sufficiency) elevate the limb to be perpendicular to the horizontal should be recorded.1 In a variation of the Buerger test, plane, which would cause pallor in patients with clini- the affected limb should be elevated to 60º from the cally significant peripheral vascular disease.1 On horizontal plane for 2 minutes, and then the limb gradual lowering of the limb, the angle at which the should be placed in the dependent position for another

The Journal of the American Osteopathic Association February 2017 | Vol 117 | No. 2 125 SPECIAL COMMUNICATION

2 minutes.5 Limb pallor during this test indicates pe- Conclusion ripheral disease, as does rubor in the dependent Physicians should consider using the Buerger test when position. Although Buerger noted that the angle of peripheral vascular disease is suspected.3,6 The finding the leg that results in pallor is a valuable adjunct in the of erythromelalgia remains distinct from erythema as- recognition of the extent of circulatory disturbance sociated with skin and soft-tissue infections. When in- and prognosis, no studies have been published, to the fection is present, tenderness, , and cutaneous authors’ knowledge, that correlate specific angles to warmth over the affected region will often be elicited, the degree of arterial occlusion. indicating necrosis or purulence complicating a gangre- nous limb.7 Patients with skin and soft-tissue infections usually have a predisposing condition such as ulcers, Sensitivity and Specificity wounds, cutaneous fissuring, or toe-web intertrigo, as of the Buerger Test well as a history of saphenous removal, radiation To better understand the diagnostic value of the therapy, or venous stasis disease.7 Erythema due to in- Buerger test, Insall et al5 collected data among 55 fection will remain on elevation of the affected limb.7 patients (30 of whom had positive results using a The Buerger test emphasizes the continued importance variation of the Buerger test) with disabling claudi- of a meticulous bedside examination, which remains cation. The authors5 reported erythromelalgia in 43% the touchstone of clinical medicine, even in an era of of patients with a positive test result. Although 73% growing overreliance on expensive and often delete- of patients who had a positive test result had palpable rious dye-based imaging studies. femoral pulses, popliteal and posterior tibial pulses were palpable in 7% of patients (no palpable dorsalis References pedis pulses were detected). Arteriography demon- 1. Buerger L. The Circulatory Disturbances of the Extremities: strated that 93% of arterial occlusions occurred Including Gangrene, Vasomotor and Trophic Disorders. below the inguinal ligament, and occlusions below Philadelphia, PA: WB Saunders Company; 1924:128-129, 162-165,214-215,390. the adductor hiatus were reported to be statistically 2. Luft FC. Leo Buerger (1879-1943) revisited. Am J Med Sci. significant among these patients (31% Buerger posi- 2009;337(4):287. doi:10.1097/MAJ.0b013e318198d030 5 tive, 0% Buerger negative; P<.01). In a critical re- 3. McGee SR, Boyko EJ. Physical examination and chronic view of patients with suspected chronic ischemia of lower-extremity ischemia: a critical review. Arch Intern Med. 1998;158(12):1357-1364. the lower extremities, McGee and Boyko3 reported a 4. Schwartz RW, Freedman AM, Richardson DR, et al. sensitivity of 100% and specificity of 54% of the Capillary blood flow: videodensitometry in the atherosclerotic Buerger test (positive likelihood ratio, 2.2; negative patient. J Vasc Surg. 1984;1(6):800-808. likelihood ratio, 0). 5. Insall RL, Davies RJ, Prout WG. Significance of Buerger’s test in the assessment of lower limb ischaemia. J R Soc Med. The cumulative evidence from these studies sug- 1989;82(12):729-731. gests that the Buerger test may be highly sensitive 6. Endean ED, Sloan DA, Veldenz HC, Donnelly MB, Schwarcz TH. Performance of the vascular physical for detecting arterial occlusions below the popliteal examination by residents and medical students. fossa but is not specific for arterial occlusion above J Vasc Surg. 1994;19(1):149-154. the popliteal fossa. Although the specificity is low, 7. Hirschmann JV, Raugi GJ. Lower limb cellulitis and its mimics: part II: conditions that simulate lower limb the high sensitivity suggests that a positive Buerger cellulitis. J Am Acad Dermatol. 2012;67(2):177,e1-e9. test result indicates probable occlusive peripheral doi:10.1016/j.jaad.2012.03.023 vascular disease. © 2017 American Osteopathic Association

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