Lymphedema

Bone bruises of the tibia have been extensively studied using MRI technology. It is now verified that bone bruising is a common injury accompanying meniscal, ligamentous, and other injuries. (3,4,6) This case study presents bone bruising that occurred throughout the tibia along with an occult fracture of the lower tibia and fibula. There was also bruising of the fibula to a lesser degree. Significant lymph tissue involvement caused secondary problems with edema, as well as pain. This paper will look at lymph involvement secondary to bone bruising and the relationship between the two.

The subject underwent open reduction and internal fixation following a fall from a mountain bike. Correction of bony alignment and fixation of the tibia was provided by a rod secured by four screws. The fibula was not corrected. (See Figures 1 and 2).

The subject presented for treatment 4 weeks after the surgery. Initial assessment indicated a significant loss of normal ankle range of movement into dorsi-flexion of about 20 degrees less than a 90 degree angle. (See Figure 3) There was also a loss of plantar-flexion of about 20 degrees. Subtalar mobility was normal.

Pitting edema of the left leg below the knee caused the following circumference measurements:

[FIGURE 1 OMITTED]

Myofascial mapping and tissue motility palpation, as developed by Sharon Weiselfish-Giammatteo, (8) were used to assess for bone bruises and lymph system dysfunction. Both were found to be positive in this subject.

It has been shown that the incidence of bone bruise, in cases of knee ligamentous injury, is about 80%. (3) This is in a case where force is transferred from soft tissue into bone, following a vector consistent with the mechanism of injury. Therefore it is reasonable to assume that the prevalence of bone bruise in bone surrounding a fracture site, where force is transmitted directly through bony tissue, is at least 80% or even higher, likely 100%. Thus it is paramount to consider that, when treating for fracture, one should also be treating bone bruising.

Bone bruise histology consists of micro-fractures of cancellous bone as well as edema and bleeding in the bone marrow. Necrosis was also found in the bone marrow because of "protrusion of fragments of hyaline cartilage mixed with highly fragmented bony trabecules." (6) Ward et al., in their study of diffusion changes to post traumatic bone marrow, found that marrow injury where trabecular damage was present, allowed "increased movement or diffusion of interstitial water relative to normal marrow. The magnitude of diffusion change appears to reflect the severity of marrow injury." (7) This change to homeostasis in the lower leg environment and the disruption of normal osmotic fluid transfer accounts for the high incidence of venous and lymph related swelling and edema after trauma.

[FIGURE 2 OMITTED]

In one case study of a maxillary fracture, it was found that chronic eye lymphedema was related to both lymph tissue occlusion and congestion, as well as removal of lymph nodes and vessels at the time of surgery. (1) This begs the question; how much further damage is caused to the lymph tissue of the lower leg at the time of the open reduction and internal fixation procedure? The surgery, although necessary for proper bone healing and alignment, may not be without some cost, in the form of further soft tissue damage that then has to heal. Also, it has been shown that there is a biochemical response of the body to the hardware itself that causes an inflammatory response. (5) Therefore, the other factor of utmost importance in the treatment of fracture is the treatment of edema: that is, the treatment of the lymph and the skin.

The subject was treated with manual therapy techniques for bone bruising, lymph congestion, and skin motility. (8) These techniques are the original work of Sharon Weiselfish-Giammatteo and have been clinically shown to be highly effective in the management of bony and soft tissue healing.

The subject was also placed on a home program of contrast bathing, leg elevation, Neuro-fascial Process (self treatment technique devised by Weiselfish-Giammatteo), treadmill walking, and a specific exercise program, called Conscious Movement. (2)

The subject made excellent progress with these treatments. She received 13 treatments in total and now has full ankle mobility. (See Figure 4) She has returned to work and regular daily functions and pain levels have significantly decreased. She reports that, if she follows her home program, she has no pain at all.

Leg circumference measurements are as follows:

[FIGURE 3 OMITTED]

It is evident from this case study that treatment of soft tissue, especially lymph, as well as treatment of bone bruises is essential for proper healing after fracture. It is apparent that the management of the post-fracture patient requires thinking beyond the fixation of the fracture and the usual exercise regimes to restore function, and that effective treatment involves hands on treatment of all affected tissue, in a holistic manner, in order for complete healing to occur.

[FIGURE 4 OMITTED]

The use of integrative manual therapy techniques proved to be the factor that ensured proper healing and pain resolution, in an efficient and timely manner.

References

1. Akoz T., et al. Persistent lower eyelid lymphedema after Le Fort III maxillary fracture (letter) Plast Reconstr Surg, 1998, Mar.

2. Conscious Movement; a program that incorporates 10 principles of exercise therapy, copyright 2000, T. Crowell and F. Bach.

3. Johnson, Darren, et al.; Articular cartilage changes seen with magnetic resonance imaging-detected bone bruises associated with acute anterior cruciate ligament rupture. Am J Sports Med 1998, vol. 26, no.3.

4. Miller, Mark, et al.; The natural history of bone bruises; a prospective study of magnetic resonance imaging-detected trabecular microfractures in patients with isolated medial collateral ligament injuries. Am J Sports Med 1998, vol.26 no.1.

5. Pape, H.C., et al.; Biochemical changes after trauma and skeletal surgery of the lower extremity: quantification of the operative burden. Crit Care Med 2000, Oct 28(10):3441-8.

6. Rangger, Christoph, et al.; Bone bruises of the knee; histology and cryosection in 5 cases Acta Orthop Scand 1998; 69(3): 219-294.

7. Ward, R., et al.; Analysis of diffusion changes in posttraumatic bone marrow using navigator-corrected diffusion gradients. Am J Roentgenol 2000 Mar; 174(3): 731-4.

8. Weiselfish-Giammatteo, S.; Dialogues in Contemporary Rehabilitation Course Material: Integrative Diagnostics, Myofascial Mapping, Cranial Therapy Series, The Lymphatic System, (Copyright)

by Tanya Crowell, PT

Correspondence:

Tanya Crowell, PT

tcrowell@allstream.net

COPYRIGHT 2005 The Townsend Letter Group
COPYRIGHT 2005 Gale Group