Edema Assessment

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Contents
1 Introduction
2 Assessment of Edema
3 Methods to Quantitatively Assess Peripheral Edema
4 Conclusion
5 References

Introduction
Edema (/Peripheral_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.[1][2]
The rapid development of generalized pitting edema associated with the systemic disease requires prompt
diagnosis and management. [1]

Assessment of Edema
(/File:Ankle_edema_.jpg)
History - Should include:
Right foot and ankle edema- 2 weeks post-surgery
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) (/Deep_Vein_Thrombosis), cellulitis, (/Cellulitis) ruptured
popliteal cyst, acute compartment syndrome (/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) (/Heart_Failure), renal disease, or hepatic disease.
2. Changes of edema with position
3. Unilateral or bilateral edema: Unilateral edema can result from DVT, (/Deep_Vein_Thrombosis) venous insufficiency, venous obstruction by a tumor (/Oncology) (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 (/Radiation_Side_Effects_and_Syndromes), or filariasis (/Filariasis)). Bilateral or generalized swelling suggests a systemic cause, such as CHF
(especially right-sided), pulmonary hypertension (/Pulmonary_Hypertension), chronic renal or hepatic disease (causing hypoalbuminemia), protein-losing
enteropathies, or severe malnutrition.
4. Medication history and
5. Assessment of systemic diseases.[1]
Physical Examination - In physical examination, pitting, tenderness, skin changes, and temperature are evaluated.[1]

Pitting: There are two types of edema, pitting and non- pitting edema. Pitting edema is described as 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, (/Tibia) and the dorsum of the foot
(/Foot_Anatomy). Non-pitting edema is seen in lymphoedema, (/Lymphoedema) myxedema, and lipedema.[1]
Tenderness: Pain to palpation over the edematous area is associated with DVT and complex regional pain syndrome type 1
(i.e., reflex sympathetic dystrophy (/Complex_Regional_Pain_Syndrome)).In contrast, lymphoedema (/Lymphoedema)
generally does not elicit pain with palpation.
Change in skin temperature, color, and texture: Warmth in the edematous area is associated with acute DVT
(/Deep_Vein_Thrombosis) and cellulitis (/Cellulitis). Redness, shinny skin, and ulcer are to be noted. Yellow-brown
hemosiderin deposition is seen in venous insufficiency.[1] (/File:Pitting_edema.jpg)
Pitting edema
Methods to Quantitatively Assess Peripheral Edema
There are various methods used in research to assess peripheral edema.[3]

The most commonly used tools to measure edema are:

1. Volume measurements (with a water volumeter)

2. Girth measurements (with a tape measure).
3. Pitting edema assessment (based on the depth and duration of the indentation).
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).

1. Water Displacement ( Volume measurements)

The volumeter:
(/File:DVT.jpg)
 Introduced into medicine by Glisson in 1622 DVT in the right leg with swelling and redness
Utilizes the same principle of water displacement first discovered by the ancient Greek mathematician,
Archimedes, which states that the water volume displaced is equal to the volume of the object immersed in the
water.
Clear acrylic rectangular box (13″x5″x9″) with a spout at the top of one of the short sides is filled with water until water rushes out of the spout. When the water level is
stable, the patient places one foot in the volumeter, displaced water collected and measured in a graduated cylinder. The amount of water displaced in milliliters
equals the volume of the foot/ankle or hand.
For the ankle, a volumetry test can be done in either sitting or standing with knees 90 degrees in sitting and foot flat in the base of the volumeter.[3]
For the hand, the participant’s hand is placed slowly into the volumeter with forearm pronated, fingers adducted, and thumb facing the spout until the web of the
middle and ring finger rested on the stop dowel of the volumeter.[4]
Advantage - It is the gold standard tool for the measurement of edema.[5]

Disadvantages - There are various disadvantages to these methods in a clinical setting.

It is time taking as it has to be set up several minutes before the test as the water level needs to be stable.
It is difficult to move once filled with water.
It requires specialized equipments.
It is messy as they require the patients to immerse their hands in water, and it is therefore unsuitable for certain patient populations.[5]

Lower extremity edema assessment (v

(v…
…

[6]

2. Girth measurements (with a tape measure)

Circumferential Method
The circumferential method is one of the girth measurement techniques. For consistent measurements, each upper extremity or lower extremity is marked with a semi-
permanent marker at a certain part with reference to the bony prominences,[3]

Figure-of-Eight method
It is also one of the girth measurement techniques. It is more reliable than the circumferential method as it covers a bigger area. A tension-controlled measuring tape is
preferred to wrap around the ankle/foot or hand for the measurement of edema than standard tape.[5][3] A figure of 8 method is usually preferred in ankle and hand
swelling. It has its own specific points across for consistency.

A figure of 8 to measure hand swelling (/Figure_of_Eight_Measurement_of_the_Hand)

Hand Therapy - Figure of 8 Measurement

[7]

A figure of 8 to measure ankle swelling (/Figure_of_Eight_Method_of_Measuring_Ankle_Joint_Swelling)

Figure of Eight Ankle Measurement

[8]

3. Pitting edema

Assessment - Press firmly with your thumb for at least 2 seconds on each extremity

Over the dorsum of the foot

Behind the medial malleolus
Lower calf above the medial malleolus
Pit depth and the time needed for the skin to return to its original appearance (recovery time) are recorded.
The grading of edema is determined by pit depth (measured visually) and recovery time from grade 0-4. The scale is used to rate the severity and the scores are 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.[3]

Conclusion
Water displacement and ankle measurement more reliable methods
Clinical assessment highly variable due to its subjective nature
Pitting Edema

The indention recovery time (how long it takes for the indention to refill) can be helpful in determining diagnosis
There is a direct relation between the serum albumin concentration and the indention recovery time (hypoalbuminemic edema recover time is < 40 seconds)
Focus assessment on: symmetry of swelling, pain, edema change with dependence, skin findings (hyperpigmentation, stasis dermatitis, lipodermatosclerosis, atrophie
blanche, ulcerations), and history of venous thromboembolism[9]

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References
1. Trayes KP, Studdiford JS, Pickle S, Tully AS. Edema: diagnosis and management. (https://www.aafp.org/afp/2013/0715/p102.html) American family physician. 2013
Jul 15;88(2):102-10.
2. Simon EB. Leg edema assessment and management. (https://go.gale.com/ps/anonymous?
id=GALE%7CA360608988&sid=googleScholar&v=2.1&it=r&linkaccess=abs&issn=10920811&p=AONE&sw=w) Medsurg Nursing. 2014 Jan 1;23(1):44-53.
3. Brodovicz KG, McNaughton K, Uemura N, Meininger G, Girman CJ, Yale SH. Reliability and feasibility of methods to quantitatively assess peripheral edema.
(https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2705274/) Clinical medicine & research. 2009 Jun 1;7(1-2):21-31.
4. Dewey WS, Hedman TL, Chapman TT, Wolf SE, Holcomb JB. The reliability and concurrent validity of the figure-of-eight method of measuring hand edema in patients
with burns. (https://apps.dtic.mil/dtic/tr/fulltext/u2/a627942.pdf) Journal of burn care & research. 2007 Jan 1;28(1):157-62.
5. Nadar MS, Taaqi M. Reliability of Occupational Therapy Students Using the Figure-of-eight Technique of Measuring Hand Volume.
(https://www.sciencedirect.com/science/article/pii/S1569186113000235) Hong Kong Journal of Occupational Therapy. 2013 Jun 1;23(1):20-5.
. Wendy Huddleston. Lower extremity edema assessment (volumetry). Available from:https://www.youtube.com/watch?v=oR4bvb_DLjQ
(https://www.youtube.com/watch?v=oR4bvb_DLjQ). [Lasted assessed: 10th Oct, 2020]
7. University of Derby. Hand Therapy - Figure of 8 Measurement. Available from:https://www.youtube.com/watch?v=V49LQxtA95I (https://www.youtube.com/watch?
v=V49LQxtA95I). [lasted assessed: 10th Oct,2020]
. GC Ortho. Figure of Eight Ankle Measurement. Available from: https://www.youtube.com/watch?v=g_0hMZEq1iQ (https://www.youtube.com/watch?v=g_0hMZEq1iQ).
[lasted assessed:10th oct,2020]
9. EBPconsul Pitting edema (https://www.ebmconsult.com/articles/pitting-edema-assessment) Available from: https://www.ebmconsult.com/articles/pitting-edema-
assessment (https://www.ebmconsult.com/articles/pitting-edema-assessment)(last accessed 19.10.2020)

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