Lower Extremity Swelling

Lower extremity swelling is often due simply to being on one’s feet for a prolonged period. This swelling, called dependent edema, resolves after bed rest.  Swelling that does not resolve after bed rest or has other associated signs and symptoms needs to be investigated.

Differential diagnosis of lower extremity swelling

• Dependent Edema

• Deep Venous Thrombosis

• Cellulitis

• Fracture (acute or stress)

• Compartment syndrome (acute or exertional)

Appropriate management of lower extremity swelling includes:

• Be suspicious for life or limb threatening processes.  Worrisome symptoms include sudden onset of the swelling, unilateral swelling, pain, fever, or a history of trauma

• Perform an appropriate exam with the differential in min

• Obtain radiographic or laboratory information as needed.

• Recognize the need to refer.

History and physical

Dependent edema:

• Is usually mild and non-pitting.  

• Swelling increases with weight bearing.

• Decreased in the morning

• Is bilateral.

Deep Vein Thrombosis

• Can cause a life threatening pulmonary embolus if there was a recent surgery, trauma, prolonged travel or hospitalization.  

• Pregnancy or use of Oral contraceptives arre predisposing factors.  

• Is usually unilateral, with a little swelling

• Is often tender to palpation.

• Sometimes has a palpable cord in the posterior calf

Cellulitis:

• Fever

• Redness

• Tenderness

• Swelling

• Check for systemic symptoms.

Acute Fracture:

• Point tenderness to a bone

• Follows trauma or a stress fracture if there was a recent increase in activity.

Compartment syndrome must also always be looked for.  

• Following a trauma, which may have been mild, the patient will have pain out of proportion to the injury.  

• The swollen leg will be tender.  

• Range of motion in the foot will cause extreme pain in the leg. 

• Compartment pressures must be obtained to rule this out. 

• Exertional compartment syndrome has similar milder symptoms that usually reverse soon after cessation of activities

When to order x-rays?

• Trauma

• Point tender (one finger breadth width) on palpation of the bone

• Suspected Infection of the bone - R/O osteomyelitis

When to order Ultrasound?

• R/O DVT.  *Remember to have a high clinical suspicion

 Labs?

If you suspect...	Then order:
Infection	CBC
DVT	Ultrasound Arterial Blood Gases CBC PT PTT
Compartment syndrome	Compartment pressures

Management

Deep Vein Thrombophlebitis (DVT)	Ultrasound Immediate Referral for Anticoagulation Monitor for Pulmonary Symptoms
Acute compartment syndrome	Immediate referral for surgical compartment release Remove cast (if applicable)
Cellulitis	Antibiotics- po vs. im or iv Bedrest Elevation Heat
Dependent Edema	Relative Rest Elevation
Acute Fracture	Cast or Surgery as Appropriate Crutches Non-Weight Bearing
Stress Fracture	Crutches if Ambulation is Painful Cast if Cortical Break Present
Exertional Compartment Syndrome	Rest Modification of Training Orthopedic Referral for Persistent Symptoms

             Sharon Burnham, DO and Scott D. Flinn, MD

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*This web version is provided by The Brookside Associates, LLC.  It contains original contents from the official US Navy NAVMED P-5139, but has been reformatted for web access and includes advertising and links that were not present in the original version. The medical information presented was reviewed and felt to be accurate in 2001. Medical knowledge and practice methods may have changed since that time. Some links may no longer be active. This web version has not been approved by the Department of the Navy or the Department of Defense. The presence of any advertising on these pages does not constitute an endorsement of that product or service by either the US Department of Defense or the Brookside Associates. The Brookside Associates is a private organization, not affiliated with the United States Department of Defense.

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