Abstract
Background and Purpose This case report describes a patient who developed lower-extremity lymphedema secondary to orthopedic trauma and surgery and reports the response to complete decongestive physical therapy (CDP), with 8 treatment sessions over 3 months.
Case Description The patient was a 56-year-old man who sustained a right ankle displaced fibular fracture, underwent open reduction internal fixation surgery 12 days later, and developed lymphedema 4 months postinjury. The patient's impairments of the right lower extremity included increased girth, decreased ankle range of motion, and increased pain. Due to these impairments and the inability to fit into normal footwear, the patient limited activities such as ambulating long distances and climbing stairs. This limited activity restricted him from participating in his normal lifestyle activities such as walking his dog in the community and performing all necessary work duties.
Outcomes Using the truncated cone formula to measure limb volume, the limb volume of the right (involved) lower extremity decreased 368 mL as a result of CDP. The percentage of difference in limb volume between the right and left lower extremities at the initial examination was 9%, and it was reduced to less than 1% at discharge. He was independent with his home program in order to maintain the results of therapy.
Discussion Physical therapist management of secondary lymphedema due to orthopedic trauma and surgery of the lower extremity was effective in decreasing circumferential girth measurements and decreasing limb volume, thereby improving gait and allowing the patient to fit into his work and leisure shoes. The patient reported improvement in his ability to perform all work activities, and he returned to his prior level of participation in the community.
Lymphedema is the abnormal accumulation of lymph fluid in the interstitial spaces and is known to occur following trauma.1–6 There are 2 published case reports of upper-extremity lymphedema due to orthopedic trauma.5,7 One case report described lymphedema following a Colles fracture of the distal radius; however, the authors suggested the lymphedema was self-induced, with psychological factors involved.7 Another case report described a patient with a fractured distal radius who later developed lymphedema.5 In that case report, the patient underwent a closed reduction of the fracture, and a cast was applied. Subsequently, the patient required open reduction internal fixation (ORIF) surgery due to malalignment. Two months after surgery, her swelling began to increase, and the patient was diagnosed with and successfully treated for lymphedema.5 In comparison with these case reports, which described upper-extremity lymphedema treatment, this case report describes a patient's treatment after developing lower-extremity lymphedema secondary to orthopedic trauma and surgery.
When a closed bone fracture occurs, the lymphatic system responds. Lymphoscintigraphy results have shown enlargement of lymphatics and inguinal lymph nodes that drain the site of injury and bone fracture when the fracture heals without complications.8–11 Although the authors discussed the lymphatic response to a bone fracture, the mechanism by which lymphedema develops is unclear. In addition, it has been shown that lymphedema can delay wound healing.11,12 In one study, lymphedema was induced in an experimental group of rats by the surgical removal of proximal thigh lymph nodes and vessels.12 Twenty days after the development of lymphedema, a tibial fracture was created in the control and experimental groups.12 After 6 weeks, all of the rats were killed, and radiographic findings showed that the rats in the control group had bone healing and normal callus morphology, whereas the rats with lymphedema in the experimental group had delayed or no bone healing and mostly scar tissue formation.
A diagnosis of lymphedema often is made based on clinical examination findings and past medical history.2,3,6,13 Some authors have reported a difference of 2 cm in circumferential girth measurements between the involved and uninvolved limbs as a diagnostic criterion for lymphedema6,13–15 or a 200-mL volume difference via water displacement or via truncated cone formula.13–16 Many studies have compared volumetric measurements obtained with the water displacement method (considered to be the gold standard) with circumferential measurements of limb volume calculated with the truncated cone or frustrum sign model.15–20 The results of these studies showed that the findings were valid and comparable, but not interchangeable. Therefore, due to the cumbersome nature and clinical unavailability of the water displacement method, circumferential measurements were performed to determine limb volume.
There are many methods available to treat lymphedema. Interventions can be divided into 3 categories: conservative, pharmacological, and surgical. Some methods of conservative intervention include: complete decongestive physical therapy (CDP), pneumatic compression pumps, massage, and elevation.1–2,4 Complete decongestive physical therapy includes education in appropriate nail and skin care, manual lymph drainage (MLD), decongestive exercises, compression bandaging, and use of compression garments for maintaining the limb size after therapy is completed.1,4,21 Pneumatic compression pumps attach to a sleeve covering the limb via rubber tubes, and compressed air is pumped into the sleeve. This air applies compression to the limb being treated,1,4 and water is removed from the interstitial spaces. However, proteins will remain and attract fibroblasts, which creates more scar tissue and hardens the limb.1 In addition, pumps on the lower extremities have been shown to cause genital edema.4 Massage, such as effleurage, performed as the sole treatment will have limited benefit and may damage lymphatic vessels if treatment is applied with too much pressure.1,2
Considering all of the treatment options available for lymphedema management, CDP is considered a treatment of choice1,3,14,22 because it is effective at reducing lymphedema without any known side effects.1,4,14 In addition, CDP is conservative, nonoperative/noninvasive, and cost-effective because the care is transferred from the health care professional to the patient and caregivers, especially for long-term management.1
This case report describes a patient who developed lower-extremity lymphedema secondary to orthopedic trauma and surgery. Because the patient attended 8 visits to the clinic over 3 months, this case report highlights the effectiveness of CDP, with daily compression bandaging contributing substantially to a successful outcome.
Case Description
Patient History
The patient was a 56-year-old man who sustained a displaced fibular fracture of the right ankle due to a slip and fall on ice outside his home. Twelve days later, he underwent ORIF surgery of the right ankle to restore anatomical alignment and promote bone healing. His initial postoperative course was unremarkable, and he was discharged home. He was non–weight bearing on the right lower extremity in a plaster cast for 6 weeks, and he used bilateral axillary crutches to ambulate. After 6 weeks, the surgeon progressed the patient to be partial weight bearing in a controlled ankle motion boot using 2 crutches, and he began physical therapy for his ankle rehabilitation at a facility close to his home. After 2 months of being partial weight bearing, the surgeon discontinued the patient's use of the controlled ankle motion boot, and he became weight bearing as tolerated using a cane. Once he was weight bearing as tolerated without the boot, he reported that the swelling in his right foot and lower leg started to increase over the next few weeks. The increased swelling led to the necessity of wearing a surgical shoe because the patient could no longer fit into his regular shoes. He reported that the swelling was not reduced with rest, ice, elevation, or techniques utilized by his orthopedic physical therapist.
The orthopedic surgeon referred the patient to a vascular physician, who ordered a color duplex sonogram and a venous duplex examination of the lower extremities. The results of these 2 diagnostic tests showed no evidence of thrombus formation in the lower extremities, satisfactory Doppler venous signal throughout, and normal compressibility of the deep and superficial veins of the lower extremities. In addition, there was no evidence of venous obstruction or valvular incompetence of the bilateral lower extremities. After these tests were performed, the patient returned to the orthopedic surgeon, and 4 months from the time of the injury, he was clinically diagnosed with lymphedema and referred for lymphedema therapy.
Past Medical History and Systems Review
The patient's past medical history included: pulmonary embolism 4 years prior to the accident, asthma, hypertension, and palpitations. The patient's blood pressure upon initial examination was 130/90 mm Hg taken in the left upper extremity while he was sitting. The patient reported that the etiology of his pulmonary embolism was unknown, and he had no history or findings of deep vein thrombosis (DVT) at the time, so the physician decided that the prophylactic treatment for a problem in the future was to keep him on warfarin indefinitely. The patient reported adhering to his medications, and he had his blood levels checked regularly.
At the time of the accident, the patient's international normalized ratio (INR) level was between 2.0 and 3.0, which is the range his physician recommended to prevent DVT.23 Before the surgery, the patient was given a shot of low molecular weight heparin. Other medications the patient was taking included: valsartan, montelukast, diltiazem, fluticasone, and lisinopril. He worked for the Department of Homeland Security as an office manager for airport security operations. His job responsibilities required him to walk and negotiate stairs throughout the airport. Prior to the accident, he reported that walking was his main form of exercise. He lived in a house with one flight of stairs with his wife, who was a nurse.
Patient Goals
The patient verbalized that his goals were to have the swelling go down so that he would be able to move his ankle better and fit into his normal work and leisure shoes. Specifically, he wanted to be able to walk his dog again and negotiate stairs one foot after another. At work, instead of being confined to a desk, he wanted to return to all activities, including walking throughout the airport.
Examination
Upon inspection of the patient's skin and integumentary system, the patient was observed to have swelling of the right lower extremity extending from the dorsum of the foot up to the proximal calf. The vertical incision on the lateral aspect of his right ankle was well healed. During the examination, no signs of fungal infections or cellulitis were observed. No skin discoloration or red marks were present. The skin was not crusting, scaling, or macerated between the toes. There was no sweet odor, nor grayish white film.1 His toenails were not yellow, split, or flaky. The patient reported no fever, and his right lower extremity was not warm to the touch. His sensation was intact and there was no skin breakdown. His right lower extremity had a positive Stemmer sign1 compared with his left lower extremity, which was negative. A positive Stemmer sign is the inability to pinch and lift the skin on the dorsum of the foot.1,4
A plastic tape measure was used to take girth measurements at 4-cm intervals. The first measurement was taken at the metatarsal heads. From this landmark, circumferential measurements were taken at 4-cm increments going in the superior direction, and the last measurement was taken 48 cm from the first measurement, ending at the popliteal fossa.1,20 The same therapist performed all of the examination measurements. Limb volume was calculated using a computerized software program from the Academy of Lymphatic Studies.24 The circumferential measurements were entered, and the software used the truncated cone formula to calculate limb volume. Using this program, the limb volume of the left (uninvolved) lower extremity was 3,964 mL and that of the right (involved) lower extremity was 4,337 mL. The volume difference was 373 mL, which represents a 9% difference (Tab. 1).
Active range of motion (AROM) and flexibility of the patient's lower extremities were measured using a goniometer as described by Norkin and White.25 The patient's hip flexion was 0 to 100 degrees bilaterally, and his knee flexion was 0 to 110 degrees bilaterally. All ankle AROM measurements are shown in Table 2. In addition to AROM, the patient's gastrocnemius-soleus muscle flexibility was measured with the knee in 0 degrees of extension and measured 0 degrees in the right lower extremity compared with 8 degrees in the left lower extremity.25
Ankle Range of Motion at Initial Examination (Visit 1) and at Discharge (Visit 8)a
The strength of the patient's lower extremities was examined using the manual muscle testing scale of 1 to 5 and position of testing as described by Hislop and Montgomery.26 It was determined that the strength of his left lower extremity was 5/5 throughout. The strength of his right hip and knee was 5/5, the strength of his right ankle was 2/5 in dorsiflexion, inversion, and eversion and 2+/5 in plantar flexion.
The patient's static balance was assessed using the timed single-limb stance test as described by Springer et al.27 With arms crossed, the patient was asked to lift one leg, and the length of time he was able to balance on one leg was recorded using a stopwatch. The patient was able to stand and balance on his left lower extremity for 30 seconds independently; however, he was able to stand and balance for less than 1 second on his right lower extremity before he had to put his left foot back down on the floor.
The patient ambulated independently without an assistive device, weight bearing as tolerated. His gait was characterized by decreased tibial translation over his right ankle and decreased weight bearing on the right forefoot in mid to late stance compared with the left lower extremity. In addition, his right foot was in the toe-out position during the entire stance phase of gait compared with his left foot, which was in the neutral position. It was observed that the patient spent less time and had a shorter step length with the right lower extremity during stance versus the left lower extremity, and he complained of pain in the ankle joint with ambulation. Using a handrail, the patient was able to independently ascend stairs with a step-over-step pattern, but he exhibited a step-to-step pattern descending due to complaints of right ankle pain. Using a numeric pain scale,28–32 the patient was asked to rate his pain from 0 to 10. He was instructed that 0 means “no pain” and 10 means “the most intense pain imaginable.” The patient was asked to state the number he would give his pain. He rated his pain 7 out of 10, and he reported the pain was located at the ankle joint when he walked or negotiated stairs. Due to the patient's increased swelling and pain, he reported that his walking was limited and he was not able to walk his dog anymore. Because his foot and ankle were swollen, the patient reported having trouble finding socks to fit, and he was unable to wear his work and leisure shoes.
Clinical Impression
Diagnosis.
The results of the patient's ultrasound tests discussed previously enabled the physician to rule out thrombus formation, valvular insufficiency, and venous obstruction as causes of his lower-extremity swelling. Also, there was normal compressibility and Doppler signal throughout the lower extremities. Although no DVT was found in his lower extremities in the past or at the time of this current incident, post-thrombotic syndrome (PTS) is a condition that needed to be ruled out. Deep vein thrombosis typically occurs at the valve section of veins,1 and PTS is a chronic consequence of DVT when there is damage to the valves leading to long-term valvular incompetence or reflux.1,4,33 Doppler ultrasound is used to assess PTS in patients who are symptomatic, and in this case, the patient's diagnostic tests showed no valvular incompetence or venous obstruction, thus making PTS unlikely to be the cause of the swelling.
After the orthopedic surgeon reviewed the examination findings and the results of the patient's diagnostic tests, the surgeon diagnosed him with lymphedema and referred him for lymphedema therapy. According to the Guide to Physical Therapist Practice, the patient's condition would fall into the Preferred Practice Pattern 6H (“Impaired Circulation and Anthropometric Dimensions Associated With Lymphatic System Disorders”).34 Because the patient's right lower extremity was hard and nonpitting (fibrotic), did not decrease in size with elevation, and had a positive Stemmer sign1 and no infection, a diagnosis of stage II secondary lymphedema was made.1,2,13 In addition to being classified according to stage, within each stage, lymphedema can be evaluated using a severity scale.2,13 Because the volume difference between the affected and unaffected legs was 9%, the patient's lymphedema would be classified as minimal.2,13
Evaluation.
Due to his condition, the patient's impairments included: increased girth of the right lower extremity, decreased range of motion and strength of the right ankle and foot, and impaired balance. These impairments led to his decreased ability to ambulate symmetrically and inability to descend stairs in a step-over-step pattern. Due to the increased girth of his right distal lower extremity, the patient stated he was unable to find socks and shoes that fit. These factors resulted in the following disabilities: limitations in his ability to perform normal work duties and restrictions in his ambulation and participation in activities in the community.
Prognosis.
The patient was very motivated to improve his condition, although he was initially skeptical that therapy would help reduce his swelling. He was not able to attend lymphedema therapy twice a week on a regular basis due to his work schedule and physical therapy sessions at another facility that focused on his ankle rehabilitation. Despite the limitations in scheduling therapy visits, it was expected that his swelling would decrease with lymphedema therapy due to the patient's willingness to adhere to his home program between therapy sessions. A reduction in right lower-extremity limb volume was expected due to his wife's ability to learn how to apply compression bandages, given her background as a nurse. In addition to daily compression, performing decongestive exercises, self-administered MLD, and appropriate nail and skin care would contribute to a positive outcome. Once the swelling decreased, the patient's risk of infection would be decreased. In addition, he would be able to report greater ease with ambulation due to decreased limb heaviness and be able to fit into his prior footwear, including those shoes necessary for his work obligations.
Plan of care.
The patient attended physical therapy for his lymphedema as often as his schedule would permit. He was educated and understood that his treatment course might be longer due to his schedule, and he was fully adherent to his home program. His plan of care was consistent with CDP,1–4,14,21 which included education in appropriate nail and skin care, self-administered MLD and exercise as a home program, and compression bandaging. The goals of therapy to be achieved by discharge included: patient and caregiver independence with a home exercise program and compression bandaging technique, decreased limb volume of the right lower extremity by 200 mL to decrease the risk of infections, and independence with donning and doffing a compression garment with 30 to 40 mm Hg of pressure in order to maintain the results of therapy.
Interventions
During the initial examination, the patient was educated on: the condition of lymphedema, appropriate nail and skin care, self-administered MLD, appropriate exercises, and the need for long-term maintenance using a compression garment. The patient was taught to clean and dry his skin after his shower and to apply a nonfragrant, hypoallergenic moisturizer with a pH around 5.0, which is the same pH as normal skin.1 In addition, the patient was educated in how to prevent infections and lymphedema exacerbations. He was told to avoid excessive heat such as saunas and hot tubs and to wear protective sunscreen and bug repellant as appropriate in the environment. The patient was informed to be careful cutting his toenails and to avoid cutting his cuticles. The patient's wife was taught how to perform MLD for her husband, and she was educated that it is beneficial to perform MLD 15 minutes once a day.1
Because the patient was undergoing physical therapy at another facility for his ankle rehabilitation, a few exercises were given to him to focus on the muscle-pump action for edema reduction. The patient was instructed to perform his exercises once a day. These exercises included: supine active ankle dorsiflexion and plantar flexion, standing bilateral plantar flexion or heel raises, standing calf stretch using the wall for upper-extremity support, and balancing on the affected leg only without using his upper extremities. Because the patient was attending physical therapy at another facility for his ankle rehabilitation, the rest of his exercises were prescribed by his orthopedic therapist at the other facility. At the initial examination, the patient signed a photographic consent and release form for publication, and photographs were taken. Figure 1 shows the patient's right (involved) lower extremity before complete decongestive physical therapy.
Patient's right (involved) lower extremity before complete decongestive physical therapy.
Following the initial examination, the patient attended 7 treatment sessions over the next 3 months. At the second session, the patient and his wife were taught how to apply multilayer short-stretch compression bandages, and they were given written instructions for home use as described by Zuther in Lymphedema Management: The Comprehensive Guide for Practitioners.1 They were instructed to keep the bandages on for 23 hours a day and remove them for skin inspection, bathing, moisturizing, and exercising every day. The patient also was informed that he needed to wear compression bandages or a compression garment when flying in an airplane.
Subsequent treatment sessions consisted of taking girth measurements and photographs and improving multilayer compression bandaging technique. During the third session, the patient's wife demonstrated her bandaging technique, and the therapist provided feedback on how to improve the amount of tension applied and how to prevent the bandages from digging in around the ankle. No other components of CDP were performed at treatment sessions. The patient was honest when he stated his adherence to the multilayer compression bandaging, ankle exercises, and nail and skin care, but he was not performing self-administered MLD. All the girth measurements at the initial examination and treatment sessions 4, 5, 7, and 8 were taken by the same therapist. At session 7, the patient was referred to a local pharmacy to be measured and fitted for an appropriate closed-toe, knee-high compression garment with 30 to 40 mm Hg of pressure. He wore the compression garment daily between sessions 7 and 8 and applied multilayer compression bandages at night as needed. During the eighth and final session, the patient was educated that for long-term maintenance, he had to wear his compression garment daily and applying compression bandages would be necessary occasionally at night or if he felt his leg was more swollen. Figure 2 shows the patient's right (involved) lower extremity after complete decongestive physical therapy. Lower-extremity limb volumes were calculated via the truncated cone formula using computerized software from the Academy of Lymphatic Studies24 (Tab. 3 and Fig. 3).
Patient's right (involved) lower extremity after complete decongestive physical therapy.
Volumetric results of lymphedema therapy.
Outcomes
Final outcome measurements were taken during the patient's last visit, session 8, which was just over 3 months from his initial examination. The patient's circumferential girth measurements improved. Using the Academy of Lymphatic Studies computerized software,24 limb volume of the right lower extremity decreased from 4,337 mL to 3,969 mL compared with 3,964 mL in the left lower extremity. Prior to treatment, the difference in limb volume between right and left lower extremities was 9%, and this difference decreased to less than 1% (ie, from 373 mL to 5 mL) at discharge23 (Tab. 1). Due to the reduction in lymphedema on the dorsum of the patient's right foot, his Stemmer sign was negative.
The AROM of bilateral hips and knees and left ankle remained the same, and his right ankle AROM measurements are shown in Table 2. In addition to AROM, the patient's right ankle gastrocnemius-soleus muscle flexibility was measured with the knee in 0 degrees of extension, and the flexibility improved from 0 degrees to 10 degrees. The patient complained of ankle pain at the end range. The patient's right ankle plantar-flexion strength remained the same at 2+/5, dorsiflexion strength improved from 2/5 to 2+/5, and inversion and eversion strength improved from 2/5 to 3−/5.
Performing the timed single-limb stance test, the patient was able to stand on his right lower extremity for 4 seconds. This was an improvement from being able to stand on his right lower extremity for less than 1 second at the initial examination. The patient's gait was still impaired, with the same characteristics as at the initial examination, most likely as a consequence of ankle pain. He reported his pain was 5 out of 10 while walking, an improvement from 7 out of 10 at the initial examination.
Upon discharge, the patient had achieved all of the goals established in the plan of care. Due to the reduction in fluid in his right lower extremity, which was maintained by wearing a compression garment, he was able to fit into all his work and leisure shoes. Usually, he wore the compression garment during the day; however, he reported applying compression bandages when he felt his leg was a little swollen. Although no formal functional outcome measurements were used, the patient reported lifestyle improvements. He reported his right leg felt lighter and walking his dog and walking at work were no longer limited. Due to continued ankle pain and a broken screw requiring further surgery, his stair negotiation technique did not improve. He could ascend stairs with a step-over-step pattern; however, he still exhibited a step-to-step pattern descending stairs and curbs due to ankle pain.
Discussion
Lymphedema may occur following trauma or surgery.1,4,5,9,35–37 Complete decongestive physical therapy is a treatment including compression, exercise, instruction in nail and skin care, and manual lymph drainage that decreases girth measurements of the affected extremity and results in improved function and activities of daily living.1,8,37 The purpose of this case report was to describe a patient with lower-extremity lymphedema as a result of orthopedic trauma and surgery and how CDP was effective with 8 sessions of therapy over 3 months.
In this case, the patient sustained a displaced right ankle fibular fracture and underwent ORIF surgery. He was diagnosed with lymphedema and referred for physical therapy. He attended 8 sessions in 3 months in addition to receiving physical therapy services for his ankle rehabilitation at another facility. During the physical therapy sessions for his ankle, he had to remove the short-stretch compression bandages. It is unknown what specific interventions for his ankle rehabilitation were performed at the other facility, and those interventions may have influenced his outcomes for range of motion, strength, balance, and gait. His 8 sessions of lymphedema therapy did not focus on improving these impairments. At discharge, the patient still complained of pain with ambulation and functional activities. During his follow-up visit with the orthopedic surgeon, a radiograph showed that one screw in his ankle had broken, which might explain his continued pain. The patient would require an additional surgery to fix the problem.
Traditionally, CDP is performed 5 days per week.1,38 There are 2 published studies that investigated the treatment of lymphedema using CDP with less frequent interventions.21,37 The study by Matthews and Smith37 compared 2 groups of patients with lymphedema. The first group comprised 5 patients who received therapy consisting of manual lymph drainage and low-stretch bandages 5 days a week for 4 weeks. The second group of 19 patients received the same therapy 2 days a week for 4 weeks and wore temporary compression garments between sessions. Both groups had a reduction in lymphedema using circumferential measurements, and there was no significant difference between the 2 groups. In a case report by Holtgrefe,21 a patient with bilateral lower-extremity lymphedema secondary to surgery and radiation for cervical cancer was treated with twice-weekly CDP. In that case report, the patient received nail and skin care education, exercises, and MLD performed during the treatment session and a home exercise program. For the compression component of CDP, the patient wore a custom-fit garment called the LegAssist-TH (Compression Design, Zeeland, Michigan). The garment was worn 22 to 23 hours a day every day. The result of treatment was a reduction of lymphedema by 10% in the right lower extremity and 9% in the left lower extremity.21
The case report by Holtgrefe21 and the study by Matthews and Smith37 share the intervention in which compression was applied 7 days a week even though the patient was seen twice a week in the clinic. Both Holtgrefe and Matthews and Smith used a form of compression garment between treatment sessions. This case report supports their findings that CDP treatment can result in decreased lymphedema even if patients do not attend therapy sessions 5 days a week as long as compression is applied 7 days a week. In this case, compression was not performed with a compression garment, but with the application of multilayer short-stretch bandages. The patient's wife was a nurse, and she was instrumental in carrying out his home program and changing the short-stretch bandages daily. This case emphasized the importance of adherence to daily compression bandaging as a component of CDP in order to decrease limb volume. The patient admitted to nonadherence to self-administered MLD, and he performed exercises during the limited amount of time when the bandages were removed.
In this lymphedema clinic, patients are typically seen twice a week until the size of the involved limb has plateaued, usually for 1 to 3 months. Then the patient is discharged with a home maintenance program and compression garment. Because the patient was seen 8 times, patient education and his home program were essential for his positive results. It is unknown whether the patient would have had such great reductions in girth measurements if he did not have his wife to assist him.
The literature shows how the lymphatic system is involved in orthopedic trauma8–11,39; however, the research addressing the treatment of posttraumatic lymphedema is limited. This case report documents the treatment of lower-extremity lymphedema following orthopedic trauma and surgery. Kasper and Meller5 reported on the treatment of upper-extremity lymphedema due to a distal radius fracture. In that case report, the patient was treated using a pneumatic compression device. It was reported that traditional treatments of a compression garment, massage, and elevation did not relieve the patient's symptoms.5 In the current case report, the patient was treated with CDP as described previously and had a positive outcome with this approach.
One limitation of this case report is that the diagnosis of lymphedema was made based upon clinical presentation and girth measurements; no diagnostic tests such as lymphoscintigraphy or magnetic resonance lymphangiography were performed.39 Although the limb volume of the patient's right (involved) lower extremity decreased to almost the same size as that of the left (uninvolved) lower extremity, no functional outcome measure was performed at the initial examination and discharge. However, the patient reported that his leg felt lighter to move and he could fit into his prior footwear. Another limitation of this study is that the left lower extremity was only circumferentially measured at the initial examination. Subsequent limb volume calculations of the right lower extremity were compared with the left leg's measurements from the initial examination. Because the patient did not have any new medical events or problems while undergoing therapy and the therapist did not observe any changes in the left leg, it was assumed that the left lower leg did not fluctuate in size throughout the duration of therapy.
Further investigation is needed for the health care community to reach a consensus on how to diagnose lymphedema and how to ascertain the prevalence and frequency of lymphedema development in patients with orthopedic injuries. The diagnosis of posttraumatic lymphedema often is missed, and this case report highlights the importance for the health care community to evaluate patients with orthopedic trauma and surgery who may have secondarily developed lymphedema. This case report describes the treatment of lower-extremity lymphedema secondary to orthopedic trauma and surgery and the effectiveness of daily compression bandaging as the most important component of CDP, even if the patient is unable to consistently attend therapy sessions.
Footnotes
-
The author thanks Ms Carolyn Padial, PT, Ms Gina Sauro, PT, DPT, Ms. Delia Gorga, PhD, OTR/L, FAOTA, and Dr Michael O'Dell for their support.
- Received March 21, 2010.
- Accepted June 19, 2011.
- © 2011 American Physical Therapy Association
References
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