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

Original Editor - Manisha Shrestha Top Contributors - Manisha Shrestha, Lucinda hampton
and Kim Jackson
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Assessment Physiopedia
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Acute Care
Acute Care - Assessment and Examination

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Oedema Assessment
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Original Editor - Manisha Shrestha Top Contributors - Manisha Shrestha, Lucinda hampton
and Kim Jackson

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Top Contributors - Manisha Shrestha, Lucinda hampton and Kim Jackson

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

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Introduction​[ edit | edit source ]

Right foot and ankle edema- 2 weeks post-surgery

Oedema 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 Oedema​[ edit | edit source ]

History - Should include:

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), cellulitis, ruptured
popliteal cyst, acute compartment syndrome from trauma, or recent initiation of calcium
channel blockers. The chronic accumulation of more generalized edema is due to the
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onset or exacerbation of chronic systemic conditions, such as congestive heart failure
(CHF), renal disease, or hepatic disease.
 2. Changes of edema with position
3. Unilateral or bilateral edema: Unilateral edema can result from DVT, venous insufficiency,
venous obstruction by a tumor (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, or filariasis). Bilateral or generalized
swelling suggests a systemic cause, such as CHF (especially right-sided), 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]

Pitting edema

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, and the dorsum of the
foot. Non-pitting edema is seen in 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).In contrast,
lymphoedema generally does not elicit pain with palpation.

DVT in the right leg with swelling and redness

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Change in skin temperature, color, and texture: Warmth in the edematous area is
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associated with acute DVT and cellulitis. Redness, shinny skin, and ulcer are to be noted.
 Yellow-brown hemosiderin deposition is seen in venous insufficiency.[1]

Methods to Quantitatively Assess Peripheral Oedema​[ edit

| edit source ]
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:

Introduced into medicine by Glisson in 1622

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]

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 Lower extremity edema asse…
asse…

[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

Hand Therapy - Figure of 8 M…

M…

[7]

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A figure of 8 to measure ankle swelling
Physiopedia
 Figure of Eight Ankle Measur…
Measur…

[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​[ edit | edit source ]

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

Pitting Oedema

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)
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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​[ edit | edit source ]

1. Trayes KP, Studdiford JS, Pickle S, Tully AS. Edema: diagnosis and management. American
family physician. 2013 Jul 15;88(2):102-10.
2. Simon EB. Leg edema assessment and management. 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. 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. 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. Hong Kong Journal of Occupational Therapy.
2013 Jun 1;23(1):20-5.
6. Wendy Huddleston. Lower extremity edema assessment (volumetry). Available
from: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. [lasted assessed: 10th Oct,2020]
8. GC Ortho. Figure of Eight Ankle Measurement. Available from:
https://www.youtube.com/watch?v=g_0hMZEq1iQ. [lasted assessed:10th oct,2020]
9. EBPconsul Pitting edema Available from: https://www.ebmconsult.com/articles/pitting-
edema-assessment(last accessed 19.10.2020)
Retrieved from "https://www.physio-pedia.com/index.php?
title=Oedema_Assessment&oldid=312963"
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