Managing Lymphedema in Fracture Care

Current Concepts and Treatment Principles

Christopher Thomas, DO; Jessica T. Le, DO; Emily Benson, MD

Disclosures

J Am Acad Orthop Surg. 2020;28(18):737-741. 

In This Article

Abstract and Introduction

Abstract

Lymphatic flow plays a notable role in the regulation of bone formation and remodeling. Chronic accumulation of the lymph fluid within tissues may lead to issues with proper bone healing after fractures, emphasizing the importance of proper management of lymphedema after trauma. Many associated risk factors place patients at risk for lymphedema, including previous surgery with nodal dissection, radiation therapy, infection, malignancy, family history of congenital lymphedema, and trauma. The benchmark imaging technique for the diagnosis of lymphedema is lymphoscintigraphy. Other modalities include duplex ultrasonography, CT, and MRI. First-line conservative treatment of lymphedema is compression. Complete decongestive therapy or complex physical therapy, also known as decongestive lymphatic therapy (DLT), has shown positive results in reducing lymphedema. Surgical interventions aim to either reconstruct and restore function of the lymphatic system or debulk and reduce tissues and fluids. Understanding the significance of lymphedema on bone healing and techniques available to recognize it are important factors in preventing delay in diagnosis and ensuring proper management of lymphedema after trauma.

Introduction

One of the notable causes of lymphedema of the extremities is trauma. Almost every orthopaedic surgeon, regardless of subspecialty, treat fractures resulting from trauma. Mechanical injury to bones and surrounding soft tissues often disrupts lymphatic pathways putting patients at increased risk of developing chronic lymphedema. Lymphedema is defined as an abnormal accumulation of the lymph fluid in tissues after damage to the lymphatic system, infection, or congenital abnormalities.[1,2] Lymphedema may also be characterized by the insufficient drainage of the lymph fluid from the extremities; the presence of lymphedema delays wound and fracture healing.[3] In a rat tibial fracture model, looking at the effects of lymphedema on fracture healing, periosteal reactions, and bone formation were insufficient because of disruption of osteoclast and osteoblast activity.[3] Significant research has demonstrated the impact of orthopaedic trauma on the lymphatic system; however, few studies address the direct treatment of posttraumatic lymphedema.[4–7] Because lymphatic flow plays a significant role in the regulation of bone formation and remodeling, chronic accumulation of lymph fluid within tissues may lead to issues with proper bone healing after fractures.[3] As such, appropriate management of lymphedema after trauma is key to optimal patient care. Prompt intervention after trauma to reduce lymph fluid accumulation can effectively prevent the development and progression of lymphedema.

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