Oedema Assessment

Original Editor - Manisha Shrestha Top Contributors - Manisha Shrestha, Lucinda hampton and Kim Jackson

Original Editor - User Name

Top Contributors - Manisha Shrestha, Lucinda hampton and Kim Jackson  

Introduction

Edema is defined as a palpable swelling produced by an accumulation of fluid in the intercellular tissue that results from an abnormal expansion in interstitial fluid volume. The fluid between the interstitial and intravascular spaces is regulated by the capillary hydrostatic pressure gradient and the oncotic pressure gradient across the capillary. The accumulation of fluid occurs when local or systemic conditions disrupt this equilibrium, leading to increased capillary hydrostatic pressure, increased plasma volume, decreased plasma oncotic pressure (hypoalbuminemia), increased capillary permeability, or lymphatic obstruction.

The rapid development of generalized pitting edema associated with the systemic disease requires timely diagnosis and management. 

Assessment of Edema

History

The history should include:

1. Timing of the edema- since when?: Acute swelling of a limb over a period of less than 72 hours is more characteristic of deep venous thrombosis (DVT), cellulitis, ruptured popliteal cyst, acute compartment syndrome from trauma, or recent initiation of calcium channel blockers. The chronic accumulation of more generalized edema is due to the onset or exacerbation of chronic systemic conditions, such as congestive heart failure (CHF), renal disease, or hepatic disease.
2. Whether it changes with position
3. If it is unilateral or bilateral: Unilateral edema can result from DVT, venous insufficiency, venous obstruction by a tumor (e.g., tumor obstruction of the iliac vein), lymphatic obstruction (e.g., from a pelvic tumor or lymphoma), or lymphatic destruction (e.g., congenital vs. secondary from a tumor, radiation, or filariasis). Bilateral or generalized swelling suggests a systemic cause, such as CHF (especially right-sided), pulmonary hypertension, chronic renal or hepatic disease (causing hypoalbuminemia), protein-losing enteropathies, or severe malnutrition.
4. Medication history and
5. Assessment of systemic diseases.

Physical Examination

In physical examination, pitting, tenderness, and skin changes, and temperature are evaluated.

• Pitting: It describes an indentation that remains in the edematous area after pressure is applied. Its location, timing, and extent are determined for treatment response. It is mainly assessed on the medial malleolus, the bony portion of the tibia, and the dorsum of the foot.
• Tenderness to palpation over the edematous area is associated with DVT and complex regional pain syndrome type 1 (i.e., reflex sympathetic dystrophy).In contrast, lymphedema generally does not elicit pain with palpation.
• Change in skin temperature and color: Warmth in the edematous area is associated with acute DVT and cellulitis. Redness, shinny skin, and ulcer are to be noted. Yellow-brown hemosiderin deposition is seen in venous insufficiency.

Methods to Quantitatively Assess Peripheral Edema

There are various methods to assess the peripheral edema quantitatively. Among all of the methods, water displacement and ankle circumference had shown a high inter-examiner agreement (intraclass correlation coefficient 0.93, 0.96 right; 0.97, 0.97 left). Whereas pitting edema assessment based on the depth and duration of the indentation is the classic method that is mostly practiced. Each method has its own pros and cons.

This subjective and invalidated clinical assessment was first described by Seidel et al. In this assessment, an examiner applies pressure with his/her index finger to a single location on the patient’s ankle. This technique is repeated at three anatomical locations (the lower calf at 7 cm proximal to the midpoint of the medial malleolus, behind the medial malleolus, and the dorsum of the foot). It captures pit depth and the time needed for the skin to return to its original appearance (recovery time) as a single edema score ranging from 0 to 4. The grading of edema is determined by pit depth ( measured visually) and recovery time. The scale is used to rate the severity and the score is as follows:

Grade 0: No clinical edema

Grade 1: Slight pitting (2 mm depth) with no visible distortion that rebounds immediately.

Grade 2: Somewhat deeper pit (4 mm) with no readily detectable distortion that rebounds in fewer than 15 seconds.

Grade 3: Noticeably deep pit (6 mm) with the dependent extremity full and swollen that takes up to 30 seconds to rebound.

Grade 4: Very deep pit (8 mm) with the dependent extremity grossly distorted that takes more than 30 seconds to rebound.

Ankle Circumference

Ankle circumference was measured in centimeters at a single location as described by Mora et al.15 For consistent ankle circumference measurements, each ankle was marked with a semi-permanent marker at approximately 7 cm proximal to the midpoint of the medial malleolus. Unlike the method outlined by Mora et al,15 a tension-controlled measuring tape (Gulick II, Lafayette Instrument Company, Lafayette, IN), rather than a standard measuring tape, was used to minimize measurement error due to differences in the amount of tension applied.

3. Figure-of-Eight

The figure-of-eight method uses eight landmarks on the ankle and foot to measure ankle circumference in centimeters: (1) midway between the tibialis anterior tendon and the lateral malleolus, (2) distal to the tuberosity of the navicular, (3) proximal to the base of the 5th metatarsal, (4) tibialis anterior tendon, (5) distal to the distal tip of the medial malleolus, (6) Achilles tendon, (7) distal to the distal tip of the lateral malleolus, and (8) back to origin.14,16,26,28 Unlike the previously published methods, a tension-controlled measuring tape, rather than a standard measuring tape, was wrapped around the ankle/foot following the eight landmarks.

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