Musculoskeletal Assessment - Edema and soft tissue

Question 1

What is edema

Answer 1

Abnormal condition of body tissues when they contain an excessive amount of tissue fluid

Question 2

Where can edema be? and How can the condition be?

Answer 2

• Located in the intercellular OR interstitial spaces
• Local to a region or diffuse throughout the body
• Acute or chronic conditions

Question 3

What are the mechanisms of edema

Answer 3

• increased hydrostatic pressure
• reduced osmotic pressure
• increased vascular permeability

Question 4

How does increased hydrostatic pressure result in edema?
give example

Answer 4

• high pressure in blood vessels pushes fluid into tissue spaces
• Cardiovascular disease

Question 5

How does reduced osmotic pressure result in edema

Answer 5

• Osmotic pressure within blood vessels is not high enough to draw fluid from the tissue spaces

Question 6

How does increased vascular permeability result in edema

Answer 6

• Blood vessel wells become more permeable and fluid drains into tissue spaces
• Tissue injury

Question 7

How is infection related to edema

Answer 7

• can cause local or widespread edema
• Local: wound infection; cellulitis of affected tissue
• Widespread: sepsis

Question 8

Examples of how medications, surgeries and medical procedures can be related edema

Answer 8

-Meds such as corticosteroids
- Surergy, mastectomy (breast cancer with lymph node removal)
- Medical procedures - IVs can cause edema

Question 9

How is immobility related to edema

Answer 9

• When you move muscles pump fluid
• sitting , lying (bedridden) for prolonged periods of time
• Deep vein thrombosis

Question 10

What are som common causes of systemic edema

Answer 10

• Cardiovascular or pulmonary diseases (CHF, pulmonary edema, pneumonia, COPD etc)
• Kidney disease
• Liver disease
• Venous insufficiency
• Diabetes/peripheral neuropathy
• Lymphatic system dysfunction/obstruction
• Electrolyte imbalance ie Increase in sodium causes fluid retention
• Toxins
• Sepsis
• Hormonal/pregnancy or prementstrual

Question 11

Systemic causes of edema signs

Answer 11

• Systemic edema - usually B/L
• Distal edema in legs, feet, hands especially in dependent positions
• Chronic edema: with related trophic changes → skin discolored, dry scaly skin, hair loss, thick nails

Question 12

what is non pitting edema

Answer 12

• no depression when pressure is applied

Question 13

Pitting edema

Answer 13

• pressure leaves a depression
• chronic and systemic

Question 14

Brawny edema

Answer 14

• hard and chronic
• Associated with venous insufficiency
• Brownish skin discoloration
• Ulcers associated with this

Question 15

Tissue injury and damage stage of acute MSK injury edema

Answer 15

• hemodynamic process
• bleeding , inflammatory response → swollen/edema warmth

Question 16

Vasoconstriction stage of acute MSK injury edema

Answer 16

• stop bleeding (hemostasis)
• platelets, cellular debris, fibrin involved in coagulation/clotting

Question 17

Vasodilation stage of acute MSK injury edema

Answer 17

• Mediated by mast cells releasing histamine; bradykinins increase vessel permeability and capillary pressure

Question 18

Transudate edema

Answer 18

• clear
• water, proteins, electrolytes and cellular elements pushed into interstitium

Question 19

Exudate edema

Answer 19

• viscous
• with increased tissue damage, capillary cells separate
• Plasma proteins and RBCs leak thru capillaries resulting in greater swelling and edema

Question 20

MSK injury edema

Answer 20

• edema resolves in a shorter time
• progression thru healing stages:

Question 21

what are the stages of healing that are associated with MSK injury healing

Answer 21

• Hemostasis: coagulation
• inflammatory : transudate, macrophages
• Fibroblastic: collagen, extracellular matrix (can do controlled mobility to scar tissue)
• Remodeling: scar maturation and alignment

Question 22

What does it mean if edema is pronounced in 2-4 hours

Answer 22

• bleeding is the cause

Question 23

if edema occurs 8-24 hours

Answer 23

• inflammatory response without significant bleeding

Question 24

Ecchymosis

Answer 24

• post injury or trauma and surgery
• Bleeding, bruising
• Swelling with discoloration usually red → purple → yellow

Question 25

Hematoma:

Answer 25

Muscle trauma: bleeding, swelling, mass of clotted blood in the tissue

Question 26

What happens when blood from hematoma is not reabsorbed

Answer 26

- Myositis ossificans; calcification or blood clot - Palpable and hard - Detected on X Ray 3-6 weeks

Question 27

Joint effusion

Answer 27

- Excessive fluid in the joint - Extrasynovial into capsule - Reflex inhibition surrounding muscle

Question 28

Hemarthrosis - what should be done for this and why?

Answer 28

- Blood in joint - Aspirate – blood i s descriptive to articular cartilage so it must be taken out

Question 29

Venous insufficiency - signs and symptoms

Answer 29

- edema , varicose veins; pulses present - Skin brownish color, onion skin, stasis ulcers - Pain with prolonged standing, dependent position - Relieved: elevation & compression, compression garments

Question 30

Arterial (PAD) - signs and symptoms

Answer 30

- Extremity cold, pale, bluish - Decreased, absent pulses - (+)capillary refill test and + rubor dependency test - Pain with exercise (vascular claudication) - Muscle need blood

Question 31

Where do DVTs commonly occur?

Answer 31

iliac, femoral, popliteal

Question 32

when can a DVT occur and cause symptoms

Answer 32

- Prolonged bed rest after surgery, trauma, blood, transfusion - immobility , air travel

Question 33

Signs and symptoms of DVT

Answer 33

- ach/pain in calf, heaviness of LE, swelling, redness

Question 34

DVT referral to MD

Answer 34

- Medical referral advised if moderate or greater probability of DVT (with goodman and synder scale) - MD: orders doppler studies, venography - Treatment: bed rest, anticoagulants, no exercise, activity, massage, filter placement in inferior vena cava

Question 35

Prevention of DVT

Answer 35

- Intermittent pneumatic device compression in bed at hospitals - Ankle pumping - Exercise - Early ambulation after surgery

Question 36

Exam for edema: what to look for during the History, interview and systems review:

Answer 36

- Systemic disease, vascular problems - Surgery, trauma/tissue injury, immobility, air travel

Question 37

Exam for edema: Observation:

Answer 37

- Edema = local or diffuse - U/L or B/L - Color, ulcers/wounds, infection, atrophy, trophic changes

Question 38

Exam for edema: Palpation purpose/findings?

Answer 38

amount, pitting, brawny hard, warm temperature, tenderness

Question 39

Exam for edema: Pulses:

Answer 39

Pulses: Femoral, popliteal, dorsalis pedis, posterior tibialis

Question 40

Exam for edema:

Question 41

Exam for edema: Capillary refill:

Answer 41

Squeeze nail bed - color should return in 3 sec

Question 42

Exam for edema: rubor dependency

Answer 42

- patient supine, check soles of feet is pink/tan color - Elevate leg to 60º note color change (white or gray) - Have patient sit at table edge and lower leg - Color should return 2-3 minutes - If it runs bright red color = PAD

Question 43

exam for edema: Measure edema:

Answer 43

girth tape measurements or volumetrics

Question 44

Exam for edema/DVT special tests

Answer 44

- Special tests: suspect DVT - wells DVT clinical prediction rule, Homans

Question 45

Interventions for edema (PT)

Answer 45

- PRICE - Exercise - Edema control/elevation - Intermittentent compression pump - patient education to avoid dependent positions

Question 46

- edema control by PT

Answer 46

- retrograde massage, - compression with ace bandage, stocking/glove - Cuban or string wrap (Fingers and toes)