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