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| Mysterious swelling can be managed with therapyThe good news for Julia Gibson was that her cancer was long gone. The bad news was the unexplained swelling in her arm years after her radiation. The lump was gone. The cancer was gone. But five years later, the surgery and treatments she'd had were instigators of a new problem in her life. Gibson, 62, stood with her arms raised in front of a mirror. She compared arms, scrutinized her right, and noted, "I have no elbow." It looked swollen, and she'd been having trouble fitting it into the sleeve of her blouses. The Port Colborne woman was worried because the swelling was on the same side as the breast cancer she'd had in 2000. She'd had the lump removed as well as some lymph nodes under her arm, which later tested positive for cancer. After that, she had eight months of chemotherapy and five weeks of radiation. Her arm became infected, turning red and hot. Her doctor prescribed antibiotics, but the infection kept coming back. Finally, she told her oncologist, who recognized the problem right away: Lymphedema. See also: arm lymphedema Simply put, it's a chronic swelling in one part of the body, caused by a problem with the lymphatic system. Think of the lymph network as a sort of waste-disposal system. The network runs alongside blood vessels and its job is to remove impurities. Primary lymphedema happens at birth or any time in life, for unknown reasons that relate to a malformation of the lymphatic system. Secondary lymphedema is triggered by a trauma, surgery or treatment such as radiation. But often it happens months, even years, afterwards. There hasn't been a lot of research, so it's not understood why some people who have surgery and radiation develop lymphedema while others never do, said Anna Kennedy, executive director of the Lymphovenous Association of Ontario. Nonetheless, it begins when the lymph nodes are either damaged or removed. Lymph nodes are like traffic lights that direct the flow of lymph fluid, which contains specialized disease-fighting cells. If nodes are damaged or removed - most commonly through cancer surgery and treatments - then traffic doesn't flow as well. It's like four lanes of a highway reduced to two. All you need is one accident (something as simple as a scratch that triggers an infection) and everything starts to back up, said Kennedy. Fluid backs up and causes swelling. Without treatment, that swelling can cause problems that range from an infection called cellulitis (red, blotchy skin with sudden fever and chills) to hardening of the skin, delayed wound healing and pain from heaviness - and, of course, psychological distress. Trouble is, few family doctors even recognize the signs, said Kennedy, herself a lymphedema patient who woke up one morning with a grossly swollen leg. It had been five years since her surgery for cervical cancer. There is no cure for lymphedema, although it can be successfully managed with a treatment called combined decongestive therapy (CDT), which includes an intensive phase to reduce swelling and a long-term maintenance phase to keep the swelling down. Gibson's treatments were reduced to once a month. And instead of a tight bandage, she wears a $500 compression sleeve custom-made in Germany. She only takes it off at night. Gibson also uses special skin cream to keep her arm soft and prevent cracking and infections. And even though the compression sleeve is hot in the summer and a reminder of the cancer she once had, she's not complaining. "You know what? I'll take it," Gibson said. "I feel blessed that I have a solution to my problem. I'm living. I'm enjoying my life." http://www.nugget.ca/ArticleDisplay.aspx?e=993821 | | |
| Avera Medical Minute: LymphedemaAvera Medical Minute: Lymphedema at 12:16 PM CST Story Updated: Feb 6, 2008 at 9:37 AM CST Rhonda Newton from Tyler, Minnesota has lymphedema. She manages it through physical therapy and routine exercise. Lymphedema is a common side effect of mastectomy's. Rhonda had a double mastectomy and all of her lymph nodes removed on her right side in December of 2006. (Definition of Lymphedema: Lymph is a clear fluid that is carried through very small channels throughout the body (much like blood is carried through blood vessels). Blocking the flow of this fluid results in the build up of lymph in the surrounding tissues. It can occur any where on the body but commonly appears most notably in either the arms or the legs and is called lymphedema. It can be a primary or secondary disorder characterized by the accumulation of lymph in soft tissues, caused by inflammation, obstruction, or removal of lymph channels.) Paula Jones is Rhonda's physical therapist. She says, " When you've disrupted the pathway of the lymph system, you get a back up of fluid in the arm or leg. The main treatment is a manual lymph drainage massage to open up alternative pathway. It's an intensive massage that lasts an hour." Rhonda is a quilter and was cutting material when she noticed swelling and pain in her forearm a month after her surgery (January 2007). Her oncologist immediately sent her to physical therapist Paula Jones at Avera McKennan Outpatient Therapy. Rhonda says, "I do my exercises each day, massages each day. I've learned to bandage myself every evening. Through coming here I learned to manage it and I do the best I can so I can do my daily routine. It's a great balancing act now. I have to exercise my arm, but not over exercise it or over use it." Rhonda has to be really careful with her right arm. That means never getting her blood pressure taken on her right arm or get blood drawn there because the slightest amount of trauma to that area could cause a flare up. Paula says, "You can't fix it. Once you have it, you control it." Rhonda beat breast cancer, went through two rounds of chemo therapy, two surgeries and endured radiation... now she's learned to live with lymphedema. Rhonda no longer cuts fabric since that may have triggered the lymphedema. She wears bandages every night to keep the fluid from building up. For more information go to www.averamckennan.com http://www.ksfy.com/news/health/15313201.html | | |
| Lymphedema of the Hand and Forearm Following Fracture of the Distal RadiusLymphedema of the Hand and Forearm Following Fracture of the Distal
Radius
By David A. Kasper, DO, MBA; Menachem M. Meller, MD, PhD ORTHOPEDICS
2008; 31:172 February 2008
Lymphedema of the hand following a fracture of the distal radius is a
rare complication resulting from abnormal protein-rich fluid
accumulation in the affected area. Although lymphedema affects
approximately 2.5 million Americans and frequently is associated with
breast cancer treatment, its occurrence in the context of a
commonplace injury to the wrist is virtually nonexistent.1
The etiology of lymphedema development following fracture care is
poorly understood and has been attributed to psychogenic causes. Only
one case of lymphedema following a Colles fracture has been reported
in the literature.2 In that report, the patient was a 42-year old man
who presented with lymphedema after a fall while accidentally being
pulled by a chain. After closed reduction of the fracture and
immobilization, the patient reported intense pain without swelling.
Immediately after removal of the patient's final cast, his hand began
to swell, and he underwent intense physiotherapy, numerous
sympathetic nerve blocks, and hospitalization with no improvement.
The authors suggested the pathogenesis of the patient's lymphedema
after his fracture was self-induced and psychogenic in nature.
This article presents a case of Colles fracture complicated by
nonpitting edema in a 62-year-old woman in whom psychogenic causes
were not identified.
Case Report
A 62-year-old right hand-dominant woman fell down a few steps at work
onto her outstretched right hand. Evaluation in the emergency room
indicated a fracture of the distal radius, and the patient underwent
closed reduction (Figure 1) under general anesthesia without a
tourniquet. This resulted in excellent restoration of the skeletal
alignment. She was placed in a well-padded short arm cast.
At a routine follow-up visit 10 days later, the patient had complete
loss of position, with the fracture reverting to the presurgical
misalignment sustained immediately following the injury. She
subsequently underwent open reduction and internal fixation using a
dorsal plate. Both the surgery and postoperative course were
uneventful.
The patient's history included controlled hypertension, mitral valve
prolapse, gastroesophageal reflux disease, rheumatic fever, scarlet
fever, and a prior arthroscopic knee procedure. She reported no prior
malignancies, and she was compliant with routine general medical
care. Psychological profiling was normal
Following cast removal, the patient began occupational and physical
therapy. Two months postoperatively, the swelling persisted, and she
developed increasing asymmetry. She also had progressive nonpitting
edema. The patient reported having no pain, hypersensitivity, or
other symptoms. She also reported she did not develop any other
illnesses or malignancies during this time.
The patient underwent an extensive workup that included
electrodiagnostic studies and radiographs of the cervical spine,
right shoulder, and right wrist (Figure 2). Computed tomography and
magnetic resonance imaging revealed prominent edema adjacent to the
capsule (Figure 3). An intravenous Doppler study ruled out deep vein
thrombosis of the right upper extremity. A Duplex arterial scan and
technetium bone scan revealed no pathological findings other than the
fractured wrist.
Her fracture healed satisfactorily without additional loss of
position. However, the function of her right hand was limited by the
edema (Figure 4). Traditional treatments, such as a Jobst gauntlet
(BSN-Jobst, Inc, Charlotte, North Carolina), Kinesio taping (Kinesio,
Albuquerque, New Mexico), massage, elevation, and Isotoner gloves
(Totes Isotoner Corp, Cincinnati, Ohio) supplemented by home
exercises failed to relieve her symptoms.
Treatment subsequently was prescribed with the NormaTec PCD
(pneumatic compression device; NormaTec, Newton Center,
Massachusetts), and the patient initially used it at home for 4 hours
daily. Within 2 weeks, her massive forearm edema dramatically
diminished, and her wrist and hand motion normalized. She was able to
bring her fingertips down to the proximal palmar crease with good
grip, pinch, and opposition.
To inhibit the recurrence of the edema and hand stiffness, the
patient has continued to use the device at home approximately 1 hour
per week. She requires no compression garments and has not had any
episodes of cellulitis (Figure 5).
Discussion
Although lymphedema is a common and severely disabling medical
condition, it has not been described following orthopedic injuries
such as a Colles fracture. The only previously published case report
describing this injury combination attributed the lymphedema to
psychogenic causes.2 In our patient, psychogenic causes were not
identified.
Lymphedema results when the lymphatic volume in tissue exceeds the
lymphatic transport system's capabilities to clear the fluid.
Increased hydrostatic pressure or decreased plasma oncotic pressure
creates gradients across the capillary membranes, which causes the
excess fluid to spill and accumulate in the interstitial space.
Possible causes of this excess fluid production include local
inflammation, surgery, infection, cancer, lymphatic obstruction (ie,
due to scarring), and trauma.3 Although all body tissues are bathed
in interstitial fluid, the lymph circulation still remains a complex,
dynamic, and incompletely understood process.4
Lymphedema can be classified into two types: primary and secondary.
Primary lymphedema is associated with hypoplastic, hyperplastic,
missing, or impaired lymph vessels. Other presentations are
classified further by age of onset. However, causes of primary
lymphedema are generally unknown and cannot be linked to any specific
traumatic event. The most common cause of primary lymphedema is
lymphangiodysplasia.
Secondary lymphedema can be attributed to trauma to the lymph nodes
or the lymphatic vessels themselves. Secondary lymphedema frequently
is seen in surgical patients and is attributed to lymphatic
obstruction.3 Speculations suggest secondary lymphedema associated
with trauma is a consequence of an infectious or inflammatory
process.3
Mechanical injury of the soft tissues and bones of the extremities
usually is followed by edema distal to the site and at the site
itself but not proximal to it. Patients usually present with a
sensation of fullness and pain in the affected area, induration,
edema, hyperkeratosis, and xerosis. Functional limitations include
decreased range of motion, joint inflexibility, decreased mobility
(if the lower limb is affected), and decreased activities of daily
living (eg, grooming and dressing).3
For several decades, treatments to relieve lymphedema and traumatic
or postoperative edema included manual massage, gradient compression
stockings and sleeves, bandaging, taping, and pneumatic compression
devices previously referred to as lymphedema pumps. All of these
treatments used external compression, but none produced consistently
good clinical outcomes. Additionally, these treatments used static
compression strategies, with compression applied and held constant
for varying lengths of time. Most of the lymphedema pumps were poorly
bioengineered, and their designs lacked understanding of the optimum
parameters for noninvasive compression.
Recently, the concept of pneumatic medicine was developed to more
clearly characterize and advance the science of external compression
strategies. As defined by Avery et al,5 pneumatic medicine is the use
of noninvasive, dynamic compression to treat the array of peripheral
vascular disorders, including arterial insufficiency, chronic wounds,
venous insufficiency, and lymphedema.
The NormaTec PCD uses a multi-cell sleeve or boot that is placed on
the affected limb and pneumatically inflated and deflated via a
unique Peristalic Pulse dynamic compression strategy. The patented
Peristalic Pulse pneumatic waveform consists of a "pulse, gradient
hold, release" compression cycle, simulating normal physiology. It
incorporates three major physiological concepts: dynamic pulsing
compression as seen in the muscle pump of a normal limb,
directionality of flow similar to the venous and lymphatic one-way
valves, and the effective movement of fluids created by peristalsis.
The parameters of the NormaTec PCD are programmed by the physician,
and the patient then uses the device independently at home.
A full functional outcome for our patient, who had chronic,
clinically significant symptoms, was achieved in a brief period of
time after numerous other treatments failed. The Peristalic Pulse
compression strategy dynamically decongested the edematous tissues,
and her hand and wrist range of motion improved markedly. Our patient
has continued to use the device approximately 1 hour per week as
maintenance therapy to prevent the return of edema and upper
extremity stiffness. No compression garment is required, and
compliance with the treatment program has been excellent.
A pathological anomaly that may have been a causative agent in our
patient's proximal edema following reduction of her Colles fracture
is complex regional pain syndrome. According to the literature, the
incidence of patients with Colles fractures who develop complex
regional pain syndrome, albeit controversial, ranges between 2% and
37%.6 Although the pathogenesis is poorly understood, complex
regional pain syndrome commonly is triggered by minor injuries such
as fractures, crush injuries, peripheral nerve injuries, and other
precipitating events that involve abnormal sympathetic nervous system
activity.
Complex regional pain syndrome is characterized by pain and
tenderness that is described as burning or aching in nature and
usually occurring at a distal extremity. Patients with complex
regional pain syndrome may develop rapid bony demineralization,
trophic skin changes, and vasomotor instability that also are
disproportionate to the underlying injury.
Complex regional pain syndrome progresses through three clinical
phases. The first phase is characterized by an intense burning pain,
edema, warmth, and tenderness of a distal extremity, especially noted
around the joints. The joints become stiff, and pain is reproduced on
passive and active motion of the joint. During the second phase (3 to
6 months), the patient's skin becomes thin, cool, and shiny. In the
third phase (another 3 to 6 months), the skin becomes atrophic and
dry, with progression to flexion contractures and palmar
fibromatosis.3
To aid in the diagnosis of complex regional pain syndrome, plain
radiographs of patients with fractures may exhibit spotty rarefaction
(Sudeck atrophy). Other tests used to substantiate this diagnosis
include thermography, bone scan, and sympathetic blockade.
The key component to successful conservative treatment is early
diagnosis within 6 to 8 weeks. Conservative treatment modalities
include heat, elevation, and desensitization. Chronic disability
occurs when the diagnosis and subsequent treatment is delayed.
However, some authors have suggested there is no correlation among
age, adequacy or number of reductions, or severity of fracture in
patients who present with complex regional pain syndrome.3 In our
patient, we ruled out complex regional pain syndrome because
electromyography, nerve conduction study, radiographs, intravenous
Doppler study, duplex arterial scan, and technetium bone scan
revealed no pathologic findings other than the fractured wrist.
Some patients present with this syndrome after age 40 years, with the
highest incidence in the sixth decade of life. Some patients also
present with this anomaly after requiring repeated fracture
reductions. Itzchaki et al2 suggested there may be a psychogenic
component to this syndrome. Emotional instability was identified in
one third of patients with this syndrome.2
Other causes of lymphedema were evaluated extensively in our patient.
Local, regional, and metastatic causes such as breast cancer and
Pancoast tumor were ruled out as were mechanical dysfunctions such as
thoracic outlet syndrome and Milroy disease. Neurological involvement
also was ruled out based on normal electroencephalographic readings
and nonpathological clinical and physical findings.
The surgical procedure in our patient was uncomplicated and thus
lymphedema secondary to any vascular injury was ruled out. Questions
that need to be addressed are whether the lymphedema was locally or
systemically mediated, or whether the onset of the fracture induced
an avascular anastomosis that led to the lymphedema. Our conclusions
led us to believe the development of lymphedema of the distal radius
following Colles fracture was idiopathic in our patient.
References Norton S. Managing lymphedema. Advance. 2000; 11(10):1-6.
Itzchaki M, Ben-Hur N, Ashur H. Lymphedema of the hand following a
fracture of the distal radius. Int Surg. 1978; 63(1):29-30. Patel AT.
Lymphedema. In: Frontera WR, Silver JK, eds. Essentials of Physical
Medicine and Rehabilitation. 1st ed. Philadelphia, PA: Hanley and
Belfus; 2002:575-577. St Louis JD, McCann RL. Lymphatic System. In:
Townsend CM, ed. Sabiston Textbook of Surgery. 16th ed. Philadelphia,
PA: WB Saunders Co; 2001:1446-1450. Avery KB, Solomon AD, Weber RB,
Jacobs LF. Treatment of congenital lymphoedema with sequential
intermittent pneumatic compression therapy. The Foot. 2000; 10(4):210-
215. Stern PJ, Derr RG. Non-osseous complications following distal
radius fractures. Iowa Orthop J. 1993; 13:63-69. Authors Drs Kasper
and Meller are from the Department of Orthopedic Surgery, Veterans
Hospital, University of Pennsylvania, Philadelphia, Pennsylvania.
Drs Kasper and Meller have no relevant financial relationships to
disclose.
Correspondence should be addressed to: Menachem M. Meller, MD, PhD,
Department of Orthopedic Surgery, Veterans Hospital, University of
Pennsylvania, 424 Stemmler Hall, Philadelphia, PA 19104-6081.
OrthoSuperSite
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| The Need for Lymphedema Education: A Patient's PerspectiveThe Need for Lymphedema Education: A Patient's Perspective
Anonymous Patient With Lymphedema
This is a patient's opinion about the need for lymphedema education.
The person wishes to remain anonymous so as not to risk identification
of the facility where her experience occurred. She has given
permission for the newsletter to print the article and was thrilled
that the Lymphedema Management SIG wanted her opinion.
I was a 43-year-old community-health nurse, a mother of two with no
family history of breast cancer when I was diagnosed with infiltrative
ductal carcinoma in 1997. Not having worked in an oncology setting
since my student days, I reviewed my 1970s-era medical-surgical
textbook on breast cancer etiology, treatment, and complications. On
the day of my preoperative assessment, I asked my healthcare provider
what complications I should be prepared for, including specifically
asking what the chances were of developing lymphedema after breast
cancer treatment. I was told that I did not have to worry about
lymphedema, as it did not occur anymore following breast cancer
treatment with current procedures.
Over the 12 weeks after surgery and in the midst of radiation therapy,
I experienced successively an infection of the breast treated with
oral antibiotics, transient swelling and tenderness of the affected
forearm monitored with observation only, lymphangitis and septicemia
resolving with oral antibiotics, and septicemia, lymphangitis, and
erysipelas with extreme swelling and blistering of the affected arm,
requiring several weeks of IV antibiotics. The final episode of
septicemia led to chronic and moderately severe lymphedema (greater
than 2,000 ml difference in limb volume as compared to the
contralateral limb), which continues today.
Based on my personal experiences and the observed experiences of
friends and colleagues who are breast cancer survivors, I believe it
is honorable and ethical to inform women (and men) newly diagnosed
with breast cancer of the potential treatment outcome of lymphedema
(possibly related to surgical removal of lymph nodes and radiation
fibrosis) and of the best understanding of risk-reduction practices,
which patients can carry out as self-care activities to prevent
lymphedema development. Visit www.lymphnet.org for the latest risk-
reduction recommendations from the National Lymphedema Network.
Had I known what I know now (as the popular song goes), I would have
insisted on aggressive antibiotic therapy at the first signs of
infection and follow-up with infectious disease specialists
knowledgeable about septicemia and its management. Prevention and
management of infection is key in preventing and managing lymphedema. See also: Lymphedema People http://www.lymphedemapeople.com http://onsopcontent.ons.org/Publications/SIGNewsletters/lym/lym17.1.html
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| Interstitial magnetic resonance lymphography: is it a new method for the diagnosis of lymphedema?Interstitial magnetic resonance lymphography: is it a new method for the diagnosis of lymphedema? Int Angiol. 2007 Dec Dimakakos E, Koureas A, Koutoulidis V, Skiadas V, Katsenis K, Arkadopoulos N, Gouliamos A, Vlachos L.Vascular Unit, 2nd Department of Surgery, University of Athens edimakakos@yahoo.gr. AIM: The aim of this study was to evaluate the method of interstitial magnetic resonance lymphography (MRL) as an examination for the depiction of the lymphatic system in humans in comparison with the method of direct X-ray lymphography. METHODS: We studied 6 persons, 2 volunteers and 4 patients with clinical suspicion of lymphedema in lower extremities. We administered subcutaneous gadobutrol for the MRL with a volume of 5 mL composed of 4.5 mL of Gadobutrol mixed with 0.5 mL of lidocaine hydrochloride and after 7 days lipiodol in the lymph vessel for the X-ray direct lymphography (in 3 patients) in order to compare the findings of the two METHODS: We then followed up all individuals for 7 days for any possible side effect of the contrast agents. RESULTS: Using MRL, we depicted the lymphatic system (lymph vessels and inguinal lymph nodes) of volunteers in 60 min. Moreover, in patients we depicted several abnormalities of the lymphatic system including decreased number of lymph vessels, lymphocele and ectatic lymph vessels. X-ray direct lymphography confirmed the findings of the MRL in all cases. No side effects were observed. CONCLUSION: In our pilot study, Gadobutrol seems to be a good contrast agent for the painless depiction of the lymphatic system in humans through interstitial MRL. More extensive studies are needed in order to establish the efficacy and the dosage of Gadobutrol. PMID: 18091705 [PubMed - in process] http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=18091705&ordinalpos=3&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVDocSum | | |
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