A 19-year-old woman has had slowly progressive bilateral leg swelling since adolescence, worse on the left. The swelling begins at the dorsum of the foot, the skin is thickened and hyperkeratotic, and the examiner cannot pinch a fold of skin at the base of her second toe on either side. There are no varicosities and the pedal pulses are normal. Which feature distinguishes this condition from chronic venous oedema?

• A Positive Stemmer sign with early involvement of the dorsum of the foot ✓
• B Presence of pitting oedema that worsens through the day
• C Hyperpigmentation and lipodermatosclerosis around the ankle
• D Relief of swelling by overnight elevation

Explanation

Lymphoedema characteristically starts on the dorsum of the foot and produces a positive Stemmer sign, the inability to pinch a fold of skin at the base of the second toe due to dermal protein-rich fluid and subsequent fibrosis. Venous oedema spares the forefoot initially, is accompanied by haemosiderin pigmentation, lipodermatosclerosis and often varicosities, and responds to overnight elevation. Early lymphoedema may pit, but once fibrosis supervenes the oedema becomes non-pitting and elevation gives incomplete relief.

Reference: Bailey & Love's Short Practice of Surgery, 28th ed.

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Written and medically reviewed by the StethoPrep medical team.