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Minasian et al. Plast Aesthet Res 2022;9:18 https://dx.doi.org/10.20517/2347-9264.2021.128 Page 3 of 9

suffer from chronic sequelae such as hyperpigmentation, hyperkeratosis, delayed wound and bone healing,
[4,7]
and frequent bouts of cellulitis .
METHODS
MEDLINE searches were performed (1948 to October 2021) using the terms “PTL”, “traumatic” (and)
“lymphedema”, “lymphedema” (and) “trauma”, (and) “lymphedema” (and) “injury”. These searches
revealed 41, 106, 854 and 839 results, respectively. After excluding articles in non-English languages,
duplicates, and articles unavailable electronically, 963 studies were available. The abstracts were fully
reviewed using the inclusion criterion of lymphedema as a consequence of injury or trauma. All 30 resulting
studies were included. Relevant bibliographies of the included studies were subsequently reviewed and
included as secondary sources as well.

In this review, we first discuss available case reports and case series, with commonalities and unique
scenarios highlighted to reflect the breadth of the literature. We then review studies focused on the
diagnosis and treatment of PTL, particularly those geared toward lymphatic restoration.

INJURY PATTERNS
Musculoskeletal injuries
Musculoskeletal injuries are the most commonly reported traumatic insult leading to PTL. Acute edema to
some degree is expected with musculoskeletal trauma. However, persistent swelling after mechanical insult
diagnosed as lymphedema has been reported following a wide variety of insults and in a variety of anatomic
regions [3,13-15] .

Unsurprisingly, extensive injuries such as limb amputation with replantation have been reported to cause
[16]
secondary lymphedema . In the available literature, however, there are no reports of attempts at immediate
or delayed lymphatic reconstruction in the setting of replantation. In striking contrast, minor
musculoskeletal injuries, with contusion as the only clinical sign, can also lead to the development of
secondary lymphedema [17-19] .

The majority of reports of PTL involve fractures as inciting events. Secondary lymphedema has been
reported in fractures treated both operatively and non-operatively. Two case reports discuss the
development of lymphedema after distal radius fracture, specifically after Colles fracture. In one, the
fracture was treated non-operatively, and ipsilateral hand lymphedema developed immediately after cast
[14]
removal with persistence despite conservative measures . Interestingly, given the lack of operative
intervention, the author deemed the lymphedema self-induced and secondary to “psychogenic causes”. In
the second report, the patient’s fracture was treated operatively with open reduction and internal fixation.
Persistent ipsilateral swelling was noted immediately after cast removal, and at two months postoperatively,
the patient was diagnosed with lymphedema due to progressive limb asymmetry and non-pitting edema .
[3]

Fractures can cause secondary lymphedema in other anatomic regions as well. Many studies describe
fractures of the lower extremities as inciting injuries, including tibial, fibular, and pilon fractures [13,20,21] .
There are reports of facial and eyelid lymphedema associated with facial fractures [15,22] . Some of these
patients were examined via lymphoscintigraphy along with patients with facial lymphedema, non-traumatic
etiologies to delineate facial lymphatic flow patterns . This study identified four main lymphatic pathways
[22]
of the face, which could be evaluated with a single technetium injection at the level of the forehead, between
the eyebrows.