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 Table of Contents  
CASE REPORT
Year : 2021  |  Volume : 13  |  Issue : 1  |  Page : 50-53

Complex regional pain syndrome type 1 of the upper limb following glass cut of the third finger in a patient


Department of Physical Medicine and Rehabilitation, Ankara Etimesgut Sehit Sait Erturk Government Hospital, Ankara, Turkey

Date of Submission16-Jan-2020
Date of Acceptance11-Apr-2021
Date of Web Publication16-Jun-2021

Correspondence Address:
Dr. Mehpare Firat
Department of Physical Medicine and Rehabilitation, Ankara Etimesgut Sehit Sait Erturk Government Hospital, Ankara
Turkey
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jotr.jotr_4_20

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  Abstract 


Complex Regional Pain Syndrome (CRPS) is a chronic pain syndrome characterized with edema, autonomic dysfunction, and dystrophic changes. We present the case of CRPS in a 32-year-old male in whom the diagnosis was based on the bone scan; characterized by disabling pain, swelling, vasomotor instability, sudomotor abnormality, and impairment of motor function. This disorder usually develops after minor trauma or surgery. Its diagnosis is very difficult and based on diagnostic criteria which have been changing over last years. However, there is no golden standard in the diagnosis of this entity. Three-phase bone scan is a widely used diagnostic modality which has been proved useful in CRPS. Multidisciplinary approach is necessary for proper and quick diagnosis.

Keywords: Complex regional pain syndromes, diagnosis, scintigraphy


How to cite this article:
Firat M. Complex regional pain syndrome type 1 of the upper limb following glass cut of the third finger in a patient. J Orthop Traumatol Rehabil 2021;13:50-3

How to cite this URL:
Firat M. Complex regional pain syndrome type 1 of the upper limb following glass cut of the third finger in a patient. J Orthop Traumatol Rehabil [serial online] 2021 [cited 2021 Dec 9];13:50-3. Available from: https://www.jotr.in/text.asp?2021/13/1/50/318410




  Introduction Top


Complex regional pain syndrome (CRPS) is a chronic progressive illness with sensory, autonomic, trophic, and motor abnormalities. Treatment is difficult and controversial.[1] Although most patients with CRPS usually recover within a year after symptom onset, severe pain may persist for a long time and patients may suffer from a very low quality of life.[2]

CRPS is frequently diagnosed in patients recovering from surgery or injury.[3],[4] CRPS is a complex pain disorder that can emerge after limb trauma or a lesion in the peripheral nervous system.

The typical features include continuing pain, sensory, vasomotor, sudomotor, motor, and trophic changes as well as edema.[3] These signs provide the basis of CRPS diagnosis. The syndrome is often associated with serious impairments in the activities of daily living and ability to function.[2],[5],[6],[7]

Women were affected four times as often as men, with a median age of onset of 46 years. Upper extremities were involved twice as often as lower extremities. These findings have been supported by subsequent studies. Women have been shown to be affected as much as two to five times as often as men with the highest incidence in postmenopausal females.[8],[9],[10],[11],[12]

CRPS appears to be multifactorial with evidence in literature pointing to components of inflammation, autoimmune factors, neuronal plasticity, and autonomic dysregulation.[13]

The clinical features of CRPS are not completely understood. CRPS is characterized by severe pain, sensory disturbances, allodynia, trophic changes, such as skin atrophy or altered hair and nail growth, localized osteoporotic changes, abnormal patterns of sweating, swelling and edema, changes in skin temperature, and reduced joint range of motion. In addition, there are movement abnormalities, such as weakness, tremor, dystonia, neglect-like symptoms, alterations in body image within the painful region, and/or pain-related psychological disturbance.[1],[2],[3],[4],[5],[6] The symptoms and their severity vary significantly between patients.

Additional objective testing (thermography, triple-phase bone scan, quantitative sudomotor axon reflex test, or a trial sympathetic ganglion block) is not necessary to make the diagnosis, but in some cases may be used to support a clinical diagnosis.[14]

Although the symptoms of CRPS may spontaneously improve, aggressive treatment should not be delayed as progressive worsening of symptoms is associated with poor prognosis. Treatment of CRPS is often challenging and involves a multimodal approach of psychiatric therapy, physical therapy, medical management, and interventional procedures.[15],[16],[17],[18],[19]

A detailed description of the signs, symptoms, and medical history of CRPS could potentially facilitate an earlier and more accurate diagnosis.


  Case Report Top


A-37-year-old woman presented to our clinic with burning pain, edema, dysesthesia, and reduced range of motion of the third finger of the right hand 11 months after glass cut of the third finger. We diagnosed her with CRPS based on the Budapest diagnostic criteria and the clinical findings of pain and decreased the range of motion along with edema, hypersensitivity, and allodynia of the right hand. Clinical signs such as painful range of motion and hyperalgesia of her right hand, swollen right hand were suggestive of CRPS. There was no history of other significant medical illness. Local examination revealed erythema and swelling in the right hand. Clinical examination showed a swollen hand and tightened skin that was pale, gleaming motor findings included stiffness, heaviness, and flexion/extension restriction at wrist. The range of motion of the elbow and shoulder was normal. Neurological examination of the hand showed evidence of allodynia and hyperalgesia. The full blood count, coagulation tests, and routine blood chemistry, including electrolytes, and renal and liver functions were normal. X-ray of the right hand are normal, there were no joint erosions. A three-phase bone scintigraphy showed increased uptake in all phases in the ipsilesional arm. Pain and range of motion of the right third finger of the patient improved after oral steroids with a starting dose of 15 mg/day. She was treated with prednisolone as well as pregabalin and physical therapy. She was lost to follow-up during her treatment but re-emerged at 21 months. At that time she reported, she was largely unchanged in regards to her right-hand symptoms but did believe the pregabalin was helpful and still continued to take 300 mg daily.


  Discussion Top


CRPS is a debilitating, complex, poorly understood condition characterized by pain in a limb, in association with sensory, vasomotor, sudomotor, motor, and dystrophic changes.[20] It is often associated with limb dysfunction and psychological distress. It commonly occurs after injury to the nerve either due to trauma (trivial or major) or surgery while in 3%–11% of the cases there may not be an precipitating factor.[21],[22] The onset of CRPS is usually precipitated by a physical injury, for example, a fracture, dislocation, sprain, or surgery.[19]

The patient was female. CRPS is two- and four-fold more common in women.[17] We identified the disease in a upper extremity, similar findings which described in several studies that upper limbs most frequently involve.[23],[24] The disease usually presents within a month of injury and sometimes recognized at the second week following injury.[25],[26]

The condition is diagnosed on the basis of clinical criteria given below [Table 1].
Table 1: “Budapest” clinical diagnostic criteria for complex regional pain syndrome

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Diagnostic approach to CRPS1 is based on the patient's history and clinical manifestations.[27] Pain characteristics (hyperalgesia and allodynia with nonnoxious stimulus), physical examination findings (swelling, joint stiffness, and vasomotor instability [color, temperature, and sudomotor changes]) were diagnostic for CRPS. Standard X-rays typically demonstrate patchy demineralization in the affected part, which may be the result of disuse. Other techniques such as radiography imaging, magnetic resonance imaging and the three-phase bone scintigraphy[28] can support the clinical diagnosis. Three-phase bone scintigraphy shows increased activity in both the blood pool and static phases. Even though the bone scan increases diagnostic sensitivity, a normal bone scan does not rule out the diagnosis of CRPS.[29]

The differential diagnosis of CRPS includes inflammatory arthritis, cellulites, osteomyelitis, deep vein thrombosis, chronic vascular disorders, diabetic neuropathy, entrapment neuropathies, and malignancy.[30]

Most cases resolve (90% of CRPS symptoms resolve after 2 years), but a significant percentage.[29] If the disease progresses, the extremity becomes cold and the joint contractures appear. It's possible to observe trophic changes in late stages of the disease.[30]

Treatment of the disease is controversial.[3],[4] However, early treatment is thought to be beneficial.[31],[32],[33],[34] The treatment options include physical therapies, medication, and surgery. Elevation of the extremity, retrograde massage, contrast bath, desensitization training, fluidoteraphy, theuropathic ultrasound, whirlpool, transcutaneous electrical nerve stimulation, and physical/occupational therapy may be beneficial in CRPS.[3],[4],[8],[35],[36],[37] Calcitonin, bisphosphonates, corticosteroids, calcium channel blockers, capsaicin creams, and Vitamin C have been found to be useful in acute CRPS.[35],[38],[39],[40] Free radical scavengers such as Dimethyl Sulphoxide (topically administered) may be useful.[41] Gabapentin has been proven to be effective only in the first 8 weeks of the disease.[42] An intravenous regional guanethidine blockade does not help, and a meta-analysis does not support the use of a local anesthetic symphatic blockade.[43],[44] Surgical sympathectomy also has been used to improve symptoms.[45] Spinal cord stimulation is ineffective.[46] We immediately began the treatment with pregabalin. We also prescribed Vitamin C for its antioxidant property. We observed dramatic response to the treatment at the 4th week of follow-up. However, resolution of the symptoms was achieved due to not only medical treatment but also other interventions such as retrograde massage, elevation, contrast bath therapy, and home exercise program.


  Conclusion Top


CRPS is a challenging clinical entity and requires a multidisciplinary approach. There is no single study or laboratory test that can confirm or exclude the diagnosis. The findings could potentially result in a more reliable and earlier diagnosis of CRPS, a better differentiation from other pain disorders, and ultimately in a more targeted and effective therapy.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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