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A case of Complex regional pain syndrome (CRPS) occurring after distal radius fracture

Complex regional pain syndrome (CRPS) 

Introduction 
CRPS is a significant comorbid event. 
It can be defined as persistent neuropathic pain of an inappropriate intensity with the
absence of ongoing tissue damage.
 
Definition 
CRPS a very broad term describing excess and prolonged pain and inflammation that follows an injury to an arm or leg. 

Synonymous 
known as reflex sympathetic dystrophy (RSD), causalgia and algodystrophy

Acute and Chronic types
1-acute type is (recent, short-term)
 2-chronic (lasting greater than six months).

CRPS I and II Types 
1-CRPS type I
No peripheral nerve lesion, pain, functional impairment, autonomic dysfunction, and dystrophic changes

2-CRPS type II
 There is a nerve 
lesion or irritation (causalgia).1,2 CRPS 

3- CRPS type III
 expands the concept to include all extremity pain dysfunction 

sympathetically maintained (SMP) or sympathetically independent (SIP)
It is based on relief or persistence of pain after sympatholytic intervention. The SMP type has a better prognosis 

Clinically
The patient complains of pain, impaired recovery, muscle stiffness, joint stiffness, cold sensitivity, and functional impairment. 

Pain types
allodynia, hyperalgesia, hyperesthesia or hypoesthesia, and hyperpathia. 

Pain descriptions 
burning, throbbing, pressing, cutting, shooting, or aching.

Trophic Changes
Upper extremity signs include:
  stiffness, edema, osteopenia, atrophy of the hair and nails, hypertrophy of skin, difficulty in fine finger motion, fixed posturing, and arthrofibrosis. Osteopenia involves both cortical and cancellous bone.

Autonomic dysfunction 
Affected limb may be hot or cold. Sweating excessive or anhidrosis, vasomotor changes includes redness or bluish discoloration, and temperature intolerance are the most common symptoms of autonomic dysfunction. 

Plain Radiographs
Regional osteopenia is evident. These changes are present if there is 
significant demineralization, apparent  after a long period from onset of symptoms. Sudeck’s atrophy is diffuse osteopenia with demineralization and subchondral erosion or cysts 

Association with distal radial fracture 
 In association with a distal radius fracture, CRPS may delay or prevent recovery (Figure 1) and has a strong negative impact on health-related quality of life and function. 

Predisposing factors associated with fracture distal radius 

They include: Tight cast, compression or injury of the median or ulnar nerves, overdistraction, instability of the distal radioulnar joint and ulnar fracture may contribute to CRPS.

Treatment 
1- physiotherapy
2- sympatholytic drugs. A combination of 
two drugs a tricyclic antidepressant combined with a selective serotonin reuptake inhibitor.
3-calcium channel blockers are nifedipine (Adalat, Procardia) and amlodipine 
(Norvasc). 
4-Corticosteroids.
5-Parenteral options include neuromuscular blocking agents, ganglion blocking agents, continuous peripheral 
blocks with lidocaine, and intrathecal medications.


Reference 
Book
  • Fractures and Injuries of the Distal Radius and Carpus: The Cutting Edge (pp.247-257)
  • Chapter: 24
  • Publisher: Saunders-Elsevier
  • Editors: David Slutsky; A.Lee Osterman


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