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25 As a result of the long-term entrapment of plasma proteins in the interstitium, the tissue becomes fibrotic. In part, treatment is the same as for subacute edema, but it includes softening of the fibrotic tissue to facilitate uptake by the initial lymphatics. Softening of indurated tissue can be accomplished with low-stretch bandaging, chip bags (convoluted foam pieces covered with stockinette), foam-lined splints, silicone gel sheets, and elastomer pads (see Fig. 3-7 on CD). Neutral warmth builds up under these inserts, causing an enzymatic reaction that softens the indurated tissue.

2-3, B). Note that the pronator teres and several extrinsic muscles (muscles that originate outside the hand and have tendons that cross the wrist) are innervated by the median nerve. In some cases the musculotendinous units can cross the elbow, forearm, wrist, fingers, and thumb. The median nerve also innervates several intrinsic muscles (muscles that originate in the hand). These muscles potentially may provide movement to the thumb, index finger, and middle fingers. Fig. 2-3, C, shows the muscles innervated by the ulnar nerve.

In terms of clinical application, the vacuum created by diaphragmatic breathing moves lymph more proximal in the thoracic duct, creating a space into which the more distal peripheral edema can move. CLINICAL Pearl The key to successful edema reduction is to “remove the plug” by starting proximally at the trunk with diaphragmatic breathing and proximal exercise. 3 Therefore exercise increases the rate of arterial flow and passively stimulates the lymphatic vessels, increasing the rate of lymph flow.

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