Surface Markings of Peripheral Arteries
Essential Pulse Palpation Sites
The vascular physical examination requires systematic palpation of pulses at the brachial, radial, ulnar, femoral, popliteal, dorsalis pedis, and posterior tibial sites, with pulse intensity recorded numerically as 0 (absent), 1 (diminished), 2 (normal), or 3 (bounding). 1
Upper Extremity Arterial Landmarks
Brachial artery: Palpated in the antecubital fossa, medial to the biceps tendon; blood pressure measurement at this site is required in both arms during initial assessment to detect subclavian or innominate artery stenosis (inter-arm difference >15-20 mm Hg is abnormal) 1
Radial artery: Palpated at the wrist on the lateral (thumb) side, just proximal to the base of the thumb at the distal radius 1
Ulnar artery: Palpated at the wrist on the medial (little finger) side; Allen's test should be performed when knowledge of hand perfusion is needed 1
Lower Extremity Arterial Landmarks
Femoral artery: Palpated at the inguinal ligament, midway between the anterior superior iliac spine and pubic symphysis; auscultation for bruits should be performed at both femoral sites 1
Popliteal artery: Palpated in the popliteal fossa behind the knee with the knee slightly flexed; this is often the most difficult pulse to palpate and requires deep palpation 1
Dorsalis pedis artery: Palpated on the dorsum of the foot, lateral to the extensor hallucis longus tendon, typically between the first and second metatarsal bones; this pulse is congenitally absent in approximately 10% of the population 1
Posterior tibial artery: Palpated posterior and inferior to the medial malleolus; used along with dorsalis pedis for ankle-brachial index measurement 1
Critical Auscultation Sites
Beyond pulse palpation, auscultation for bruits is essential at specific anatomic locations to detect arterial stenosis. 1
Carotid arteries: Auscultate bilaterally in the neck, noting carotid upstroke and amplitude; presence of bruits suggests carotid stenosis 1
Abdomen and flanks: Auscultate for bruits suggesting renal artery stenosis or abdominal aortic disease 1
Both femoral arteries: Auscultate in the groin bilaterally for evidence of iliac or femoral artery stenosis 1
Abdominal Aorta Assessment
- Palpate the abdomen to detect aortic pulsation and estimate maximal diameter; this is particularly important in patients ≥65 years or those with risk factors for abdominal aortic aneurysm 1
Additional Physical Examination Findings
Complete the vascular examination by removing shoes and socks to inspect the feet for signs of arterial insufficiency. 1
Skin changes: Evaluate color, temperature, and integrity of skin; look for distal hair loss, trophic skin changes, and hypertrophic nails suggesting severe PAD 1
Elevation pallor/dependent rubor: Elevate legs to assess for pallor, then place legs in dependent position to observe for rubor (redness), which indicates severe arterial insufficiency 1
Ulcerations and gangrene: Document presence and location of any nonhealing wounds or tissue necrosis 1
Common Pitfalls to Avoid
Do not rely solely on pulse palpation: Even palpable pedal pulses do not exclude significant PAD; ankle-brachial index measurement is required for diagnosis in patients with risk factors or symptoms 1
Do not skip bilateral arm blood pressure measurement: Failure to measure blood pressure in both arms misses subclavian stenosis and leads to inaccurate ABI calculation 1
Do not assume absent dorsalis pedis pulse indicates PAD: This pulse is congenitally absent in approximately 10% of normal individuals; check the posterior tibial pulse and consider ABI measurement 1
Do not overlook asymptomatic disease: More than 70% of patients with PAD are asymptomatic or have atypical leg symptoms rather than classic claudication, making systematic examination essential even without typical symptoms 1, 2