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Edema and Lymphedema Management

Information

Description of Intervention

Edema is swelling caused by excess fluid collecting in the peripheral vascular system or the interstitial spaces of the digits, hand, wrist, forearm, or entire upper extremity.  In hand surgery patients, edema is usually secondary to trauma or surgery.  Of course, edema can also be caused by systemic illness such as congestive heart failure.  Edema, or prolonged swelling, in the hand or arm which lasts more than 5 days, may lead to fibrosis and thickening of tissues.1Edema may be detrimental to joint function, strength and aesthetics of the hand or arm.2

The greater the area of the edema, the more resistance there is to tendon gliding.3 Edema will also increase the work of flexion in the finger digits, especially in the thumb.4

Indications for Intervention

Edema is most often caused by an injury, including crush injuries, fractures, dislocations, tendon injuries or burns. It may also be due to a post-surgical reaction. In very rare cases, hand or arm edema may be caused by lymphedema or breast carcinoma.2

(Rheumatological conditions can present with slower resolving edema during flare-ups.)

Diagnosis

  1. Ask for the patient’s medical history, including any recent hand injuries (diabetes, breast cancer or axillary lymph node resection) or second-degree burns.
  2. Edematous tissues look swollen when compared to the uninjured side.  If the examiner’s finger is pushed into edematous tissue and removed, the tissue remains pitted, i.e. "pitting edema."
  3. Measure the area of edema, by using a tape measure (around bony prominences for accuracy in mm) or by immersing the arm in water (and measuring the amount of water displaced in ml). Comparing to the contralateral arm can verify the presence of edema and quantitate the amount.
  4. Check active range of motion, bilaterally.

Intervention Options

Use post-surgical or post-traumatic treatment for approximately 9-12 weeks after the surgery or injury.

Manual Edema Mobilization (MEM) techniques have been effective in treating patients with high protein edema, which is post-surgical or post traumatic. MEM includes light massage therapy, at 20 mm Hg, which facilitates interstitial pressure changes.1

In addition to light massage, treatment should include elevation, active muscle exercise and compression. Either gloves or (compressive sleeves) can be used for compression; kenesiotape will allow more freedom of movement. A self-adherent wrap is another option, to be used in conjunction with post-operative hand therapy.4 Contrast baths, in which the patient’s hand is alternately immersed in hot and cold water, have also been used to treat edema. However, the evidence to support this treatment is inconclusive.5

For edema caused by superficial second degree burns, first check the depth, location of the burns and fluid replacement. Traditional therapy can be used, but there may be more improvement in patients if electrical stimulation is added to traditional therapy.6

For edema caused by lymphatic cancer, manual lymphatic drainage (MLD) should be used. It is vital not to employ too much pressure in this treatment, because the drainage will only be successful if there are some lymphatics remaining.7

Images
Measuring edema (swelling)
  • A simple tape measure can quantitate the circumference of a finger, thumb, palm, wrist or forearm. The measurement should be made at anatomic landmarks like the radial styloid. The measurements and landmarks can be document and followed over time and compared to measurements in the univolved extremity.
    A simple tape measure can quantitate the circumference of a finger, thumb, palm, wrist or forearm. The measurement should be made at anatomic landmarks like the radial styloid. The measurements and landmarks can be document and followed over time and compared to measurements in the univolved extremity.
  • The hand volume is an excellent method for documenting hand edema. The volume of the displaced water shows the volume of the hand. The peg (arrow) standardizes the hand position in the tank.
    The hand volume is an excellent method for documenting hand edema. The volume of the displaced water shows the volume of the hand. The peg (arrow) standardizes the hand position in the tank.
Diagnoses Where This Intervention May be Relevant
Comments and Pearls
  • Patients with diabetes, rheumatoid arthritis (RA) or vascular impairment may experience a greater extent or duration of edema, in post-traumatic or post-operative situations. Timing of hand therapy should be adjusted, to allow for full recovery in these patients.5
  • It may be necessary to lessen the force of exercises, in post-operative therapy, as compared with post-traumatic therapy.3 Self adherent wraps will make the work of flexion more difficult.4
  • When walking, sitting, or lying down, keep elevated above the heart.
References
  1. Artzberger S, Rodrick J. Manual edema mobilization: a new concept in sub-acute hand edema reduction. Israel Journal of Occupational Therapy 2002: E37-63. (no pub med #)
  2. Miller LK, Jerosch-Herold C, Shepstone L. Effectiveness of edema management techniques for subacute hand edema: a systematic review. J Hand Therapy 2017;30:432-46. PMID?
  3. Cao Y, Tang JB. Investigation of resistance of digital subcutaneous edema to gliding of the flexor tendon: an in vitro study. J Hand Surg 2005 etc. PMID?
  4. Buonocore S, Sawh-Martinez R, Emerson JW, et al. The effects of edema and self-adherent wrap on the work of flexion in a cadaveric hand. 2012. PMID?
  5. tanton DEB, Lazaro R, MacDermid JC. A systematic review of the effectiveness of contrast baths. J Hand Ther 2009;22:57-70. PMID?
  6. Omar MT, El-Badawy AM, Borhan WH, et al. Improvement of edema in superficial second degree hand burn using electrical stimulation. J Plast Reconstr Surg 2004:28(2):141-7. PMID?
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