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For further information, see CMDT Part 2-07: Lower Extremity Edema

KEY FEATURES

Essential Inquiries

  • History of venous thromboembolism

  • Symmetry of swelling

  • Pain

  • Change with dependence

  • Hyperpigmentation, stasis dermatitis, lipodermatosclerosis, ulceration

General Considerations

  • Lower extremities can swell in response to

    • Increased venous or lymphatic pressures

    • Decreased intravascular oncotic pressure

    • Increased capillary leak

    • Local injury or infection

  • Chronic venous insufficiency

    • Most common cause of chronic lower extremity edema

    • Affects up to 2% of the population

    • Strong predictor of all-cause death

  • Deep venous thrombosis (DVT)

    • Most common life-threatening cause of unilateral lower extremity edema

    • Risk factors for DVT (Table 2–4)

      • History of cancer

      • Recent limb immobilization

      • Confinement to bed for at least 3 days after surgery within the last month

  • Venous insufficiency is common complication of DVT

  • Chronic edema increases the risk of cellulitis

Table 2–4.Risk stratification of adults referred for ultrasound to rule out DVT.

CLINICAL FINDINGS

Symptoms and Signs

  • Unilateral or bilateral lower extremity edema

    • Pitting with or without tenderness

    • Measure calves 10 cm below the tibial tuberosity

    • Swelling of the entire leg or one leg is 3 cm larger than the other suggests DVT

    • The left calf is normally slightly larger than the right as left common iliac vein courses under the aorta

  • Chronic venous insufficiency

    • Sensation of "heavy legs," followed by itching

    • Skin findings range from hyperpigmentation and stasis dermatitis to lipodermatosclerosis and atrophie blanche to skin ulceration

    • Stasis dermatitis: brawny, fibrotic skin changes

    • Skin ulceration

      • Shallow, large, modestly painful ulcer

      • Location over the medial malleolus is a hallmark of chronic venous insufficiency

  • Assess heart, lungs, and abdomen for pulmonary hypertension, heart failure (HF), or cirrhosis

  • Lymphedema

    • Can be difficult to distinguish lymphedema from venous insufficiency by physical examination

    • Kaposi-Stemmer sign (inability to pinch or pick up a fold of skin at the base of the second toe because of its thickness) is a significant predictor of lymphedema

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