Causes

History

A history of trauma will be obvious in many cases, although pathological fractures may occur with little trauma. Reflex sympathetic dystrophy may follow trauma, e.g. Colles’ fracture. Congenital lymphoedema of the arm is rare; however, secondary lymphoedema is not and a history of carcinoma of the breast, operations on the axilla or radiotherapy to the axilla should be sought. There may be a history of a puncture wound or flea bite, suggesting cellulitis or lymphangitis. Streptococcal cellulitis is common following puncture wounds in patients who already have lymphoedema of a limb. Axillary vein thrombosis may come on after excessive or unusual exercise and has been nicknamed ‘effort thrombosis’. An example is a patient who has been painting a ceiling who is not used to doing that sort of thing. It may occur in patients with cervical ribs or thoracic inlet obstruction. Thrombosis may also occur following insertion of a central line.

Examination

There may be localised swelling and tenderness together with crepitus associated with a fracture. There may be generalised non-pitting oedema suggestive of lymphoedema. Examination of the axilla may reveal a mass of lymph nodes, a scar suggestive of previous surgery or the skin changes of previous radiotherapy. Examination of the breast may reveal the site of a primary tumour that has resulted in secondary axillary lymphadenopathy. With axillary vein thrombosis, there will be swelling, cyanosis and prominent dilated veins on the arm. With cellulitis, there may be redness and heat in the arm, and in lymphangitis, there may be red, inflamed streaks along the line of lymphatic vessels. With reflex sympathetic dystrophy, the limb becomes painful, swollen and stiff, with a reddened, smooth, shiny appearance to the skin.

General Investigations

Specific Investigations