Synonyms:
Reflex sympethatic Dystrophy Syndrome (RSDS), Sudeck's Atrophy, Causalgia, Shoulder-Hand Syndrome, Posttraumatic Dystrophy, Sympathetic maintained pain syndrome
History:
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Recognized since the Civil War when it was called causalgia, a name chosen to describe intense, burning extremity pain after an injury.
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Bonica coined the term reflex sympathetic dystrophy in 1953
Incidence:
1% of all conservatively treated distal radius fractures and up to 5% of operatively treated fractures.
Types:
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CRPS type I
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secondary to an identifiable neurologic compression or injury.
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e.g. ulnar nerve axonotemesis or a superficial radial nerve injury due to trauma from an external fixator pin.
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CRPS type II
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no identifiable neurological injury
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sympathetically mediated pain
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Stages:
Acute:
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6-12 wks
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persistent burning pain
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trivial injury followed by severe & out of proportion pain
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Localised pain, later spreads throughout extremity
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Hypersensitivity to light touch
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Extremity swollen & warm
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Excessive perspiration
Dystrophic
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Affected joint ROM restricted
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Involved area becomes cool
Atrophic
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Skin & muscle atrophy
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Skin dry, shiny, glossy
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Stiffness, intractable pain persists several weeks
Diagnosis:
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Identify for CRPS type I or CRPS type II.
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determine if it is a treatable source (type I).
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Persistent burning pain after an injury is characteristic.
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most common lesion with type I is median nerve injury, due to direct trauma or an undiagnosed compressive neuropathy.
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causes are injury to the ulnar nerve, the superficial radial nerve, the intercarpal ligament, or the triangular fibrocartilage.
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delayed union, incomplete union, and nonunion may also contribute to symptoms.
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X-ray – Patchy Osteoporosis
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Peripheral nerve conduction studies e.g. compression points around the elbow are useful, also evaluate the ulnar nerve.
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MRI may show an incomplete union, carpal injuries, or TFCC injury.
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Arthroscopic reveal arthrofibrosis and/or TFCC injuries.
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Bone Scan +ve, showing regional uptake reflects ncreased blood flow
Treatment:
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Prevention, immediate attention, control pain & swelling.
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Restoration of motion by exercise
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Active use of extremity despite pain
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Edema control by limb elevation
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Physiotherapy
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Drugs: antidepressants, corticosteroids, calcium channel blockers
CRPS Type I:
Surgical treatment:
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Neurolysis aimed at external compression of the median and ulnar nerve injuries.
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Adjunctive grafting or Barrier wrapping for injury to sensory branches of the superficial radial or dorsal ulnar nerve.
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Neuroma resection proximally and nerve stump can be buried in appropriate soft tissue.
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External bone stimulators or revision osteosynthesis for an incomplete union.
CRPS type II
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Multifaceted, aimed at restoring ANS control and improving physical function.
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Early recognition and regional blockade with physical therapy is useful.
Medical management
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guided by the appearance of the hand and wrist (Early phases marked by erythema and swelling, later phases, they may appear cool and atrophic.
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For warm, swollen erythematous hand, treatment include gabapentin, selective serotonin reuptake inhibitors, or clonidine hydrochloride.
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In later stages, the aim is to improve blood flow, using nifedipine or selective serotonin reuptake inhibitors.
Physical therapy
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mobilizing the wrist and digits.
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Focus is to improve wrist extension, causing greater mechanical advantage.
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Adjunctive modalities such as dynamic or serial static splinting may prove effective at mobilizing the wrist and the metacarpophalangeal joints.
Prognosis
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Recovery after CRPS treatment varies.
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the prognosis for CRPS type I is better than that of CRPS type II.
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When the syndrome continues for more than 1 year, it is likely that residual impairment will be present.
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Regardless of the treatment afforded, patients experience delayed recovery.
