Transcript 1400_Bartholomew_PL54E4x

Orthopedic Causes of Edema
• John R. Bartholomew, MD, MSVM, FACC
• Section Head - Vascular Medicine
• Department of Cardiovascular Medicine
• Professor of Medicine - Cleveland Clinic Lerner College of
Medicine
• Cleveland Clinic
Clinical Causes of Edema
• Obstruction of venous and lymphatic drainage
• Congestive heart failure
• Nephrotic syndrome and other hypoalbuminemic states
• Acute glomerulonephritis and other forms of renal failure
• Cirrhosis
• Hypothyroidism (Myxedema)
• Drug-induced edema
• Nutritional
• Idiopathic edema
Common Causes of Lower Extremity Edema
Pathophysiology
Clinical Conditions
Increase of venular pressure
Venous reflux or obstruction
Cardiac insufficiency
Immobility – muscle pump failure
Lower extremity dependency
Increased capillary permeability
Hormones, drug side effects, inflammation, diabetes,
exercise
Reverse osmotic pressure difference
Renal failure, malnutrition, blood plasma protein
deficiency
Lymphatic failure
Functional decompensation, primary lymphatic
deficiency
Lipedema
Unknown
International Angiology 31(4)
Orthopedic Causes of Edema
• Common problem for orthopedic physicians
• Number of different causes
• Not a disease - a sign of an underlying disorder
• May be a minor disorder or a serious problem
Orthopedic Causes of Edema
• DVT, superficial thrombophlebitis
• Cellulitis
• Osteoarthritis
• Osteomyelitis
• Charcot’s joint
• Popliteal (Baker’s) cyst
• Trauma
• Fractures, stress fracture
• Malignant, benign tumors
• Compartment syndrome
• Gastrocnemius rupture
• Medications
• Complex regional pain syndrome
• Sport Injuries
• Factitial
• Additional causes
Orthopedic Causes of Edema
History and Physical Examination
• Patients age, sex, and race
• Comorbidities (systemic disease)
• Medications
• Mechanism of injury if applicable (trauma, immobility, surgery)
• Visualization of extremity noting deformity, swelling
• Skin examination (bruising, discoloration)
• Neurological exam documenting motor and sensory function
• Vascular exam documenting pulses (palpable or Dopplerable)
Orthopedic Causes of Edema - History
•Acuity of Onset
- DVT, SVT, gastroc tear, cellulitis,
compartment syndrome, gout, trauma,
fractures
•Chronic Onset
- medications, systemic process, tumors CRPS
Orthopedic Cause of Edema
Laboratory Tests
Routine:
- CBC and differential
- Chemistry profile
- WSR, C-reactive protein
- Thyroid tests
- SPEP
- Albumin, transferrin
- Urinalysis
Special:
- ANA, ANCA, RF
- Complement (C3, C4)
- BNP
- D-dimer
- Antiphospholipid antibodies
Cryoglobulin, cold agglutinins,
- Drug screen
Orthopedic Causes of Edema
Imaging and Vascular Laboratory
• X-ray
• Echocardiogram
• Arterial
- ABI, Doppler ultrasound
- MR angiogram
- CT angiogram
- Angiography
• Venous:
- Duplex
- Venous incompetency
- Contrast venography
- IVUS
• CT and MR imaging
• Lymphatic
- Lymphoscintigraphy
- Abd/pelvic CT or MRI
Deep Vein Thrombosis
• May be common following orthopedic procedures
including THR, TKR or acute hip fracture
• Leg swelling, erythrocyanotic appearance and leg
pain
CHEST 2008;133(6):381S-453S
Superficial Thrombophlebitis
• May result from leg
trauma
• Increased warmth,
erythema, induration
and tenderness along
the GSV, SSV, or
varicosities
• May have a palpable
cord.
Cellulitis
• Most common infectious cause of
limb swelling (strep and staph most
usual)
• Look for portal of entry (skin cracks,
fissures, tinea pedis) allowing
bacteria to enter/release toxins in
the SC tissues
Cellulitis
• Acute onset swelling, erythema, pain
• High fever, shaking chills, sweats
• Erythema not uniform - skipped areas
• Lymph nodes can be tender, enlarged
• Recurrent episodes of cellulitis and
accompanying lymphangitis can lead
to secondary lymphedema
Osteomyelitis
• Can produce limb swelling
• Susceptible patients:
- DM with neuropathy, neurotrophic ulcers
- Peripheral neuropathy
- Arterial insufficiency
- Sickle cell anemia (Salmonella)
• Spreads by:
- Hematogenous (bacteremia from cellulitis, UTI,
pneumonia)
- Trauma or surgery
- Contiguous spread (infection nearby skin, during
orthopedic surgery, animal bite, decubitus ulcer)
BMC Infectious Disease 2012;12:161-164
Charcot’s Joints/Acute Charcot Arthropathy
• Swollen and deformed joints
• Increased warmth, localized
tenderness
• Develops up to 7.5% of patients
with diabetic peripheral neuropathy
• May lead to mid foot collapse plantar deformity, ulceration and
amputation
• Nuclear scanning, MRI
J Orthopaedic Surgery and Research 2010;5(7):1-9
Popliteal Cysts (Baker’s Cyst)
• Produces swelling behind the knee or distally
• May mimic DVT
- if compression
of the popliteal vein
- If ruptures
• Physical examination should suggest popliteal cyst in
patients with RA or degenerative joint disease
• Ultrasound examination confirms unless ruptured
Popliteal (Baker’s) Cyst
Seen with knee inflammation (arthritis or cartilaginous tear)
U/S: Anechoic, crescent shaped
If ruptures – acute limb swelling and pain
Am J Phys. Med. Rehabil 2012;91(11):1002-1004
Trauma
• Fractures
• Incidental or unnoticed
trauma
• Generally accompanied by
ecchymosis
http://www.trauma.org/archive/vascular/images/vascskeletal021.jpg
Malignant and Benign Bone Tumors
Malignant Bone Tumors
• Osteosarcoma - most common
primary malignant tumor
- more common in men
- knee, proximal femur
• Chondrosarcoma - (5th and 6th decade)
- knee, pelvis and spine
• Ewing’s sarcoma - (children, young
adults)
• Lymphoma of bone - knee, pelvis, hip
Benign Bone Tumors
• Osteoid Osteoma
• Enchondroma
• Osteochondroma
• Giant cell tumor
Compartment Syndrome
• Increased pressure in a closed fascial space leading to
compromised perfusion and severe tissue damage
• Severe pain, induration and edema
• Results from local tissue response to severe hypoxemia
and/or to restoration of blood flow to an ischemic extremity
• The compartments ability to accommodate a sudden
increase in volume is limited (in a fixed, enclosed area)
especially if other mechanical factors (trauma or encasement
bandages or dressings) are present
Compartment Syndrome
Fasciotomy (prophylactic or therapeutic) may be necessary
Surg Clin N Am 2013;93:789-812
Surg Clin N Am 2012;92(4):987-1007
Drug-Induced
• Bilateral, soft, pitting edema
• Generally resolves once drug
withdrawn
• Corticosteroids, nonsteroidal
anti-inflammatory drugs
(NSAIDs)
• Hormones (estrogens,
testosterone, androgen)
Sports/Runner Injuries
• 10% to 20% of Americans run regularly
• 19% to 79% of runners are injured
• Most running-related injuries related to overuse
• Risks for running-related injuries include:
•
•
•
•
Systemic (gender, weight, knee alignment, flexibility
Running/training related (frequency, terrain, distance)
Health (previous injuries/medical problems)
Lifestyle (sedentary, work, tobacco, cross training
Med Clin N Am 2014;851-868
Sports/Runner Injuries - Other Causes of Edema
Orthopedic Conditions Encountered in Runners
• Stress fractures
• Gastrocnemius/Soleus Strain/Rupture
• Iliotibial Band Syndrome (ITBS)
• Patellofemoral Pain Syndrome (PFPS)
• Meniscal injuries
• MTSS
• Achilles tendinopathy
Med Clin N Am 2014;851-868
Stress Fractures
• Common in sports (prolonged walking, running or jumping)
• Tibia, fibula most common sites
• Risk factors
-
poor condition or preparation
rapid increase in training program
female gender, decreased bone mineral density
obesity
leg length discrepancy
poor footwear
• Shin pain, swelling, erythema and/or warmth
• Radiographs, MRI
• Conservative (immobilization non weight bearing, casting, walking boot)
Med Clin N Am 2014;851-868
JAMA 2015;313:15661567
Br J Radiology 2012;85:1148-1156
Gastrocnemius Rupture
• Weekend athlete, steps off curb (4th-5th decade)
• Sudden onset of sharp pain in calf, leg swelling
• Ecchymosis (gravitational dissection of blood from
the torn muscle through muscle tissue plains)
• Crescent shape (Scimitar Sign) beneath the malleoli
• Rupture medial head of gastrocnemius muscle
• Patients may describe a snap or pop
“Tennis Leg”
Gastrocnemius Rupture
• Unable to bear weight on leg
• May be confused with DVT (treatment with
anticoagulants worsens leg)
• Treat - ice, no weight bearing
• Initially avoid physical activity
• “Tennis leg”
Scimitar Sign
Slide courtesy of Bruce Gray DO
Iliotibial Band Syndrome (ITBS)
• Most common knee problem in
runners
• Lateral knee pain, thigh and/or hip
pain worsened by squatting, running
or with ascending/descending stairs
• Aching discomfort, swelling along the
course of ITB
• Physical therapy, ice
http://www.moveforwardpt.com/symptomsconditionsdetail
Patellofemoral Pain Syndrome (PFPS)
• Found commonly in young runners
• Pain around kneecap
• Sitting with knee flexed for a long period of time
(theater sign), climbing stairs and/or running
exacerbate the pain
• Physical exam
- popping, snapping or grinding under the kneecap
- mild swelling and small effusion
• Treatment – physical therapy, heat-molded
orthotics
http://www.sportalignment.com/img/pfs_top.jpg
Other Causes of Edema
Factitial Edema
• Self-injurious behavior leading to
deliberate harm to the body that may
result in factitial injuries
• May develop after a previous injury
• Higher prevalence in females
• Prevalence in general population
estimated at 750 per 100,000 disabled
individuals
Vascular Medicine 2002;7:56
International Journal of Paediatric Dentistry 2003;13:130-137
Other Causes of Edema
Cystic Adventitial Disease
• Rare condition - mucinous cysts form
within the adventitia of arteries and veins
• Can lead to lumen occlusion
• Young to middle-aged men
• Popliteal artery most involved site
• Painless swelling if popliteal venous cyst
J Vasc Surg 2014;60:235-245
J Vasc Interv Radiol 1996; 7: 583-586
Other Causes of Edema
Popliteal Entrapment Syndrome
• Exercise-induced (generally
strenuous) intermittent claudication
(running, cycling)
• Affects calf and foot (affects 69% of all
patients)
• Onset of symptoms often sudden
• Limb swelling (if popliteal vein
entrapment)
J Vasc Surg 2012;55:252-262
Vascular and Endovascular Surgery 2013;47:513-518
Other Causes - Klippel Trenaunay Syndrome
Clinical triad of capillary malformations, varicose veins or venous
malformations and muscular limb hypertrophy