Lymphoedema Armchair Legs

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leg swelling)

Classification of primary lymphoedema

Classification of primary lymphoedema

Elephantiasis Nostras Legs
Primary lymphoedema with bilateral below knee swelling due to hypoplasia of peripheral lymphatic vessels
Kaposi Stemmer Sign
Kaposi-Stemmer sign: inability to pinch a fold of skin at base of second toe because of thickened skin indicates lymphoedema
Lymphatic Papillomatosis Images

Dilatation of upper dermal lymphatics with consequent fibrosis Armchair legs (elephantiasis nostras gives rise to papillomatosis verrucosis) develop in patients who sit in a chair day and night with their legs dependent. Patients with with cardiac or respiratory disease, stroke, spinal damage, or arthritis are predisoposed to this condition

Lipoedema only affects women and causes swelling between hip and ankle with sparing of the foot. The condition is symmetrical. The skin and subcutaneous tissues are soft and often tender with easy bruising

Dilatation of upper dermal lymphatics with consequent fibrosis Armchair legs (elephantiasis nostras gives rise to papillomatosis

Investigation of lymphoedema

Lymphoscintigraphy (isotope lymphography)

Lymphoscintigraphy is the best investigation for identifying oedema of lymphatic origin. Radiolabelled colloid or protein is injected into the first web space of each foot and monitored using a gamma camera as it moves to the draining lymph nodes. Measurement of tracer uptake within the lymph nodes after a defined interval will distinguish lymphoedema from oedema of non-lymphatic origin. The appearance of tracer outside the main lymph routes, particularly in the skin (dermal backflow), indicates lymph reflux and suggests proximal obstruction. Poor transit of isotope from the injection site suggests hypoplasia of the peripheral lymphatic system.

Direct contrast x ray lymphography (lymphangiography)

After the lymph vessels have been identified with a vital dye, a contrast medium such as Lipiodol is administered directly into a peripheral lymphatic vessel, usually in the dorsum of the foot. In a normal limb the lymphangiogram will show opacification of five to 15 main collecting vessels as they converge on the lowermost inguinal lymph nodes. In patients with lymphatic obstruction the contrast medium will often reflux into the dermal network, so called "dermal backflow."

verrucosis) develop in patients who sit in a chair day and night with their legs dependent. Patients with with cardiac or respiratory disease, stroke, spinal damage, or arthritis are predisoposed to this condition

Lipoedema only affects women and causes swelling between hip and ankle with sparing of the foot. The condition is symmetrical. The skin and subcutaneous tissues are soft and often tender with easy bruising

Armchair Legs

Lymphoscintigraphy. Radiolabelled colloid or protein is injected into the first web space of each foot and followed with a gamma camera as it moves to the draining lymph nodes. Tracer can be seen within the main lymphatic channels and lymph nodes as well as within the infection site. Collateral drainage is seen within the left thigh

Lymphoscintigraphy. Radiolabelled colloid or protein is injected into the first web space of each foot and followed with a gamma camera as it moves to the draining lymph nodes. Tracer can be seen within the main lymphatic channels and lymph nodes as well as within the infection site. Collateral drainage is seen within the left thigh

Computed tomography and magnetic resonance imaging

Both computed tomography and magnetic resonance imaging detect a characteristic "honeycomb" pattern in the subcutaneous compartment that is not seen with other causes of oedema. In post-thrombotic syndrome the muscle compartment deep to the fascia is enlarged, whereas in lymphoedema it is unchanged. Thickening of the skin is also characteristic of lymphoedema, although it is not diagnostic. Magnetic resonance imaging is more informative than computed tomography because it can detect water.

Management of lymphoedema

Most patients with lymphoedema are just told to live with it, but this is neither necessary nor acceptable.

Honeycomb Skin Infection
Computed tomogram showing sections through normal thigh (left) and thigh with lymphoedema (right). Note thickened skin and honeycomb pattern

Physical treatment to reduce swelling

Treatment is aimed at controlling lymph formation and improving lymph drainage through existing lymphatic vessels and collateral routes by applying normal physiological processes which stimulate lymph flow.

Prevention of infection

Prevention of acute inflammatory episodes (cellulitis or lymphangitis) is crucial because they can cause severe constitutional upset and deterioration in swelling. Care of the skin, good hygiene, control of skin diseases such as tinea pedis, and careful antiseptic dressings after minor wounds are all important. Antibiotics must be given promptly when an acute inflammatory episode occurs. In recurrent cellulitis the only effective treatment is prophylactic antibiotics—for example, phenoxymethylpenicillin 500 mg daily, for an indefinite period.

Drug treatment for lymphoedema

Diuretics are of little benefit in lymphoedema because their main action is to limit capillary filtration. Improvement in patients who are taking diuretics suggests that the predominant cause of the oedema is not lymphatic. The benefit of benzopyrones, such as coumarin or flavonoids, remains unproved.

Surgery

Surgery is of value in a few patients in whom the size and weight of a limb inhibit its use and interfere with mobility after physical treatment. Surgery is aimed at either removing excessive tissue (reducing or debulking operations) or bypassing local lymphatic defects.

Peter S Mortimer is consultant skin physician, St George's Hospital and Royal Marsden Hospital, London.

The ABC of arterial and venous disease is edited by Richard Donnelly, professor of vascular medicine, University of Nottingham and Southern Derbyshire Acute Hospitals NHS Trust ([email protected] nottingham.ac.uk) and Nick J M London, professor of surgery, University of Leicester, Leicester ([email protected]). It will be published as a book later this year.

BMJ 2000;320:1527-9

Physical treatment for lymphoedema

Process

Effect

Exercise

Compression (hosiery)

Manual lymphatic drainage

Multilayer bandaging

Pneumatic compression

Elevation

Dynamic muscle contractions encourage both passive (movement of lymph along tissue planes and non-contractile lymph vessels) and active

(increased contractility of collecting lymph vessels) drainage

Opposes capillary filtration

Acts as a counterforce to muscle contractions

(so generating greater interstitial pressure changes)

Form of massage that stimulates lymph flow in more proximal, normally draining lymphatics to "siphon" lymph from congested areas (particularly trunk)

Used as an intensive treatment in combination with exercise to reduce large, misshapen lower limbs and permit subsequent maintenance treatment with hosiery Softens and reduces limb volume but can forcibly displace fluid into trunk and genitalia. Hosiery must always be worn afterwards Does not stimulate lymph drainage but lowers venous pressure and therefore filtration, allowing lymph drainage to catch up

Further reading

• Ko DS, Lerner R, Klose G, Cosimi AB. Effective treatment of lymphedema of the extremities. Arch Surg 1998;133:452-8.

• Mortimer PS. The swollen limb and lymphatic problems. In: Tibbs DJ, Sabiston DC, Davies MG, Mortimer PS, Scurr JH. Varicose veins, venous disorders and lymphatic problems in the lower limb. Oxford: Oxford University Press, 1997.

• LevickJR. An introduction to cardiovascular physiology. 2nd ed. Oxford: Butterworth-Henemann, 1995.

An old friend

It was high time I chucked away my old stethoscope. Much was wrong with that battered, grubby Littman: the rubber ring missing from the bell, the warped metal end tube, the left ear piece fallen off. All of which had little to do with the fact that I could never hear anything through it.

Junior medical days had been a nightmare, the eminent physician inviting us all to listen to his classic case of reverse splitting of the fifth heart sound, and me barely able to hear lup-dup. Eventually I developed a perverse pride in this disability: I argued that such sounds were so highly subjective that they could not support any diagnostic inference, and thus, in an epistemological sense, they were not there. I became entrenched in this view after a visit to Sri Lanka, where the chest pathology could be seen and heard from the end of the bed, just as the medical textbooks' Edwardian authors would have encountered it; and with comparable social conditions at its root. With an attitude like that, I was obviously destined for provincial obscurity and public health.

Mid-life approached, and the millennium, and a spirit of chuck out the old, bring in the new. If I was going to carry a stethoscope at all let it be a decent one. But I sensed that there were a couple of last tasks in store for the old one.

The meningitis immunisation clinic was crowded just before Christmas, so I left my paperwork, pocketed the Littman and walked up through town to lend a hand. And there it sat on the desk, like a badge of office, through a busy but rewarding day. Luckily that was all it was required to do: imagine a public health doctor using a stethoscope? That's like seeing a psychiatrist plying a tendon hammer, or an orthopaedic surgeon with a pleasant bedside manner—nice in a curiously old fashioned way.

The "holidays" were spent sitting by my beloved, occasionally fetching her juice or medicines, as machinery hissed and tubing snaked around our little bedroom. Late afternoon on Boxing Day the crisis came, her breathing faded, and her pupils widened with that vision that is beyond life. I disconnected the assorted gadgetry and noted the time. And then I solemnly placed my stethoscope on her chest, and heard absolutely nothing at all.

Graham Sutton consultant in public health, Wakefield

We welcome articles of up to 600 words on topics such as A memorable patient, A paper that changed my practice, My most unfortunate mistake, or any other piece conveying instruction, pathos, or humour. If possible the article should be supplied on a disk. Permission is needed from the patient or a relative if an identifiable patient is referred to. We also welcome contributions for "Endpieces," consisting of quotations of up to 80 words (but most are considerably shorter) from any source, ancient or modern, which have appealed to the reader.

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  • eustorgio
    How to sit and elevate legs with edema swelling?
    11 months ago

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