1. Orthopedic Causes of Edema
John R. Bartholomew, MD, MSVM, FACC
Section Head - Vascular Medicine
Department of Cardiovascular Medicine
Professor of Medicine - Cleveland Clinic Lerner College of Medicine
Cleveland Clinic

2. Clinical Causes of Edema
Obstruction of venous and lymphatic drainage
Congestive heart failure
Nephrotic syndrome and other hypoalbuminemic states
Acute glomerulonephritis and other forms of renal failure
Cirrhosis
Hypothyroidism (Myxedema)
Drug-induced edema
Nutritional
Idiopathic edema

3. Common Causes of Lower Extremity Edema
Pathophysiology
Clinical Conditions
Increase of venular pressure
Venous reflux or obstruction
Cardiac insufficiency
Immobility – muscle pump failure
Lower extremity dependency
Increased capillary permeability
Hormones, drug side effects, inflammation, diabetes, exercise
Reverse osmotic pressure difference
Renal failure, malnutrition, blood plasma protein deficiency
Lymphatic failure
Functional decompensation, primary lymphatic deficiency
Lipedema
Unknown
International Angiology 31(4)

4. Orthopedic Causes of Edema
Common problem for orthopedic physicians
Number of different causes
Not a disease - a sign of an underlying disorder
May be a minor disorder or a serious problem

5. Orthopedic Causes of Edema
DVT, superficial thrombophlebitis
Cellulitis
Osteoarthritis
Osteomyelitis
Charcot’s joint
Popliteal (Baker’s) cyst
Trauma
Fractures, stress fracture
Malignant, benign tumors
Compartment syndrome
Gastrocnemius rupture
Medications
Complex regional pain syndrome
Sport Injuries
Factitial
Additional causes

6. Orthopedic Causes of Edema History and Physical Examination
Patients age, sex, and race
Comorbidities (systemic disease)
Medications
Mechanism of injury if applicable (trauma, immobility, surgery)
Visualization of extremity noting deformity, swelling
Skin examination (bruising, discoloration)
Neurological exam documenting motor and sensory function
Vascular exam documenting pulses (palpable or Dopplerable)

7. Orthopedic Causes of Edema - History
Acuity of Onset
- DVT, SVT, gastroc tear, cellulitis, compartment syndrome, gout, trauma, fractures
Chronic Onset
- medications, systemic process, tumors CRPS

8. Orthopedic Cause of Edema Laboratory Tests
Routine:
- CBC and differential
- Chemistry profile
- WSR, C-reactive protein
- Thyroid tests
- SPEP
- Albumin, transferrin
- Urinalysis
Special:
- ANA, ANCA, RF
- Complement (C3, C4)
- BNP
D-dimer
Antiphospholipid antibodies Cryoglobulin, cold agglutinins, - Drug screen

9. Orthopedic Causes of Edema Imaging and Vascular Laboratory
Venous:
- Duplex
- Venous incompetency
- Contrast venography
- IVUS
CT and MR imaging
Lymphatic
- Lymphoscintigraphy
- Abd/pelvic CT or MRI
X-ray
Echocardiogram
Arterial
- ABI, Doppler ultrasound
- MR angiogram
- CT angiogram
- Angiography

10. Deep Vein Thrombosis
May be common following orthopedic procedures including THR, TKR or acute hip fracture
Leg swelling, erythrocyanotic appearance and leg pain
CHEST 2008;133(6):381S-453S

11. Superficial Thrombophlebitis
May result from leg trauma
Increased warmth, erythema, induration and tenderness along the GSV, SSV, or varicosities
May have a palpable cord.

12. Cellulitis
Most common infectious cause of limb swelling (strep and staph most usual)
Look for portal of entry (skin cracks, fissures, tinea pedis) allowing bacteria to enter/release toxins in the SC tissues

13. Cellulitis Acute onset swelling, erythema, pain
High fever, shaking chills, sweats
Erythema not uniform - skipped areas
Lymph nodes can be tender, enlarged
Recurrent episodes of cellulitis and accompanying lymphangitis can lead to secondary lymphedema
Skipped areas

14. Osteomyelitis Can produce limb swelling Susceptible patients:
- DM with neuropathy, neurotrophic ulcers
- Peripheral neuropathy
- Arterial insufficiency
- Sickle cell anemia (Salmonella)
Spreads by:
Hematogenous (bacteremia from cellulitis, UTI, pneumonia)
Trauma or surgery
Contiguous spread (infection nearby skin, during orthopedic surgery, animal bite, decubitus ulcer)
BMC Infectious Disease 2012;12:

15. Charcot’s Joints/Acute Charcot Arthropathy
Swollen and deformed joints
Increased warmth, localized tenderness
Develops up to 7.5% of patients with diabetic peripheral neuropathy
May lead to mid foot collapse - plantar deformity, ulceration and amputation
Nuclear scanning, MRI
J Orthopaedic Surgery and Research 2010;5(7):1-9

16. Popliteal Cysts (Baker’s Cyst)
Produces swelling behind the knee or distally
May mimic DVT
- if compression of the popliteal vein
- If ruptures
Physical examination should suggest popliteal cyst in patients with RA or degenerative joint disease
Ultrasound examination confirms unless ruptured

17. Popliteal (Baker’s) Cyst
Seen with knee inflammation (arthritis or cartilaginous tear)
U/S: Anechoic, crescent shaped
If ruptures – acute limb swelling and pain
Am J Phys. Med. Rehabil 2012;91(11):

18. Trauma Fractures Incidental or unnoticed trauma
Generally accompanied by ecchymosis

19. Malignant and Benign Bone Tumors
Malignant Bone Tumors
Benign Bone Tumors
Osteosarcoma - most common primary malignant tumor
more common in men
knee, proximal femur
Chondrosarcoma - (5th and 6th decade)
- knee, pelvis and spine
Ewing’s sarcoma - (children, young adults)
Lymphoma of bone - knee, pelvis, hip
Osteoid Osteoma
Enchondroma
Osteochondroma
Giant cell tumor

20. Compartment Syndrome
Increased pressure in a closed fascial space leading to compromised perfusion and severe tissue damage
Severe pain, induration and edema
Results from local tissue response to severe hypoxemia and/or to restoration of blood flow to an ischemic extremity
The compartments ability to accommodate a sudden increase in volume is limited (in a fixed, enclosed area) especially if other mechanical factors (trauma or encasement bandages or dressings) are present

21. Compartment Syndrome
Fasciotomy (prophylactic or therapeutic) may be necessary
Surg Clin N Am 2013;93:
Surg Clin N Am 2012;92(4):

22. Drug-Induced Bilateral, soft, pitting edema
Generally resolves once drug withdrawn
Corticosteroids, nonsteroidal anti-inflammatory drugs (NSAIDs)
Hormones (estrogens, testosterone, androgen)

23. Sports/Runner Injuries
10% to 20% of Americans run regularly
19% to 79% of runners are injured
Most running-related injuries related to overuse
Risks for running-related injuries include:
Systemic (gender, weight, knee alignment, flexibility
Running/training related (frequency, terrain, distance)
Health (previous injuries/medical problems)
Lifestyle (sedentary, work, tobacco, cross training
Med Clin N Am 2014;

24. Sports/Runner Injuries - Other Causes of Edema
Orthopedic Conditions Encountered in Runners
Stress fractures
Gastrocnemius/Soleus Strain/Rupture
Iliotibial Band Syndrome (ITBS)
Patellofemoral Pain Syndrome (PFPS)
Meniscal injuries
MTSS
Achilles tendinopathy
Med Clin N Am 2014;

25. Stress Fractures
Common in sports (prolonged walking, running or jumping)
Tibia, fibula most common sites
Risk factors
poor condition or preparation
rapid increase in training program
female gender, decreased bone mineral density
obesity
leg length discrepancy
poor footwear
Shin pain, swelling, erythema and/or warmth
Radiographs, MRI
Conservative (immobilization non weight bearing, casting, walking boot)
Med Clin N Am 2014;
JAMA 2015;313:
Br J Radiology 2012;85:

26. Gastrocnemius Rupture
Weekend athlete, steps off curb (4th-5th decade)
Sudden onset of sharp pain in calf, leg swelling
Ecchymosis (gravitational dissection of blood from the torn muscle through muscle tissue plains)
Crescent shape (Scimitar Sign) beneath the malleoli
Rupture medial head of gastrocnemius muscle
Patients may describe a snap or pop
“Tennis Leg”

27. Gastrocnemius Rupture
Unable to bear weight on leg
May be confused with DVT - (treatment with anticoagulants worsens leg)
Treat - ice, no weight bearing
Initially avoid physical activity
“Tennis leg”
Scimitar Sign
Slide courtesy of Bruce Gray DO

28. Iliotibial Band Syndrome (ITBS)
Most common knee problem in runners
Lateral knee pain, thigh and/or hip pain worsened by squatting, running or with ascending/descending stairs
Aching discomfort, swelling along the course of ITB
Physical therapy, ice

29. Patellofemoral Pain Syndrome (PFPS)
Found commonly in young runners
Pain around kneecap
Sitting with knee flexed for a long period of time (theater sign), climbing stairs and/or running exacerbate the pain
Physical exam
popping, snapping or grinding under the kneecap
mild swelling and small effusion
Treatment – physical therapy, heat-molded orthotics

30. Other Causes of Edema Factitial Edema
Self-injurious behavior leading to deliberate harm to the body that may result in factitial injuries
May develop after a previous injury
Higher prevalence in females
Prevalence in general population estimated at 750 per 100,000 disabled individuals
Vascular Medicine 2002;7:56
International Journal of Paediatric Dentistry 2003;13:

31. Other Causes of Edema Cystic Adventitial Disease
Rare condition - mucinous cysts form within the adventitia of arteries and veins
Can lead to lumen occlusion
Young to middle-aged men
Popliteal artery most involved site
Painless swelling if popliteal venous cyst
J Vasc Surg 2014;60:
J Vasc Interv Radiol 1996; 7:

32. Other Causes of Edema Popliteal Entrapment Syndrome
Exercise-induced (generally strenuous) intermittent claudication (running, cycling)
Affects calf and foot (affects 69% of all patients)
Onset of symptoms often sudden
Limb swelling (if popliteal vein entrapment)
J Vasc Surg 2012;55:
Vascular and Endovascular Surgery 2013;47:

33. Other Causes - Klippel Trenaunay Syndrome
Clinical triad of capillary malformations, varicose veins or venous malformations and muscular limb hypertrophy