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Complex Regional Pain Syndrome (CRPS)

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
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