Complex regional pain syndrome type I. Risk factors, prevention and risk of recurrence

Dorsal bridging plates for the treatment of high and low energy distal radius fractures

Distal radius fractures are common and treatment of complex fracture pattens can be challenging. We assessed functional outcomes, radiographic analysis, and complications of 26 distal radius fractures treated with dorsal bridging plate (DBP) at a mean of 14 months post plate removal (6-34 months). Radiographic parameters were measured pre- and post-operatively and patient reported wrist evaluation scores, patient reported wrist range of movement and satisfaction scores. Mean post-operative total PRWE was 26 (range 0-76) and mean wrist mobility 52° flexion (range 10°-85°) and 50° extension (range 10°-85°). Mean post-operative patient satisfaction score was 89% (range 50-100%). Four patients developed complications (one EPL rupture and three developed CRPS). DBP can reliably restore distal radius anatomy and is associated with good functional outcome scores, return of functional range of wrist movement and high levels of patient satisfaction.

Level of Evidence

III.

A randomised placebo-controlled clinical trial on the efficacy of local lidocaine injections and oral citalopram for the treatment of complex regional pain syndrome

BACKGROUND

Complex regional pain syndrome (CRPS) is a neuropathic pain condition with no universally recognised treatment. The study evaluates the efficacy of a therapeutic protocol consisting of oral citalopram and lidocaine injections in patients affected by CRPS.

METHODS

Between January 2010 and December 2014, 150 consecutive patients with CRPS were enrolled in the study and randomly assigned into three groups: group one - lidocaine injection and oral citalopram; group two - lidocaine injection and oral placebo; and group three - injective and oral placebo. The Impairment Sum Score (ISS) was used to assess the severity of CRPS before, as well as at regular intervals after treatment commenced. Statistical significance (p < 0.05) was determined by paired t-tests.

RESULTS

The combined treatment proved to be more effective (ISS 47.6 to 12.6) than local anaesthetic alone (ISS 47.5 to 21.5) and to placebo (ISS 47.2 to 29.9).

CONCLUSION

This study indicates that CRPS may be managed with well-tolerated association of oral citalopram and lidocaine injections.

The challenge of recognizing severe pain and autonomic abnormalities for early diagnosis of CRPS

OBJECTIVES

Complex regional pain syndrome (CRPS) is a disabling usually post-traumatic pain condition. International guidelines emphasize early diagnosis for treatment and improved outcome. Early intense and persistent pain along with features of autonomic dysfunction in the first week's post-injury are early warning signs for development of CRPS. We have previously reported a delayed diagnosis of CRPS. The main purpose of the present study was to investigate possible causes of a delayed diagnosis, with a special focus of recognition of risk factors.

METHODS

A total of 52 CRPS 1 (without detectable nerve damage) and CRPS 2 (with evidence of nerve lesion) patients were included in the study. When examined at OUS-Rikshospitalet, we retrospectively asked the patients on the development of pain and autonomic abnormalities from the time of the eliciting injury, performed a thorough clinical investigation with an emphasis on signs of autonomic failure and compared symptoms and clinical findings with such information in previous medical records. We also evaluated symptoms and signs according to the type of injury they had suffered.

RESULTS

Of a total of 52 patients (30 women and 22 men, mean age 39.0 years at the time of injury), 34 patients had CRPS type 1 (65.4%) and 18 CRPS type 2 (34.6%), 25 patients with pain in the upper and 27 in the lower extremity. A total of 35 patients (67.3%) were diagnosed with CRPS (following mean 2.1 years) prior to the investigation at OUS-Rikshospitalet (mean 4.86 years following injury). Mean time from injury to diagnosis was 33.5 months (SD 30.6) (2.8 years) for all patients. In retrospect, all 17 patients first diagnosed at OUS met the CRPS diagnosis at an earlier stage. All patients retrospectively reported intense pain (numeric rating scale > 7) from the time of injury with a large discrepancy to previous medical records which only stated intense pain in 29.4% of patients with CRPS type 1 and 44.4% of patients with CRPS type 2 within the first four months. While the patients reported an early onset of autonomic dysfunction, present in 67.3 and 94.2% of the patients within one week and one month, respectively, reports of autonomic abnormalities within the first four months was far less (maximum in 51.7% of patients with CRPS type 1 and in 60% in CRPS 2). In 10 patients with CRPS type 1, no symptom nor sign of autonomic abnormalities was reported.

CONCLUSIONS

We still find a significant delay in the diagnosis of CRPS. There is a large discrepancy between both self-reporting of intense, disproportionate pain, as well as symptoms of autonomic abnormalities from the time of injury, and documentation in previous medical records. Our findings suggest a lack of awareness of risk factors for the development of CRPS, such as early intense pain and autonomic abnormalities without recovery, contributing to delayed diagnosis. The present results suggest causes of delayed CRPS-diagnosis. An increased attention to early warning signs/risk factors may improve diagnosis of CRPS.

A randomized controlled trial on Aspirin and complex regional pain syndrome after radius fractures

Complex regional pain syndrome (CRPS) is often diagnosed in patients who are recovered with surgery or injury. CRPS is usually diagnosed in patients recovering from distal radius fractures. The aim of study was the effects of aspirin in prevention of the complex regional pain syndrome (CRPS) following a fracture of distal radius. In a double-blind, randomized controlled trial, 91 patients with unilateral extra-articular distal radius fractures were randomly allocated to receive either placebo (PLA) or 500 mg of aspirin (ASA) daily for 7 days. The effect of aspirin on the occurrence of CRPS was evaluated. The patients were assessed clinically and radiographically in the second, fourth and twelfth weeks by a physician who was unaware of the treatment allocation. Ninety-one patients (ASA, n=44; PLA, n=47) were enrolled in the study. The prevalence of CRPS in all patients was 16.5%. The prevalence of CRPS in the aspirin group was lower (13.6%) than the placebo group (19.1%), but this difference was not statistically significant. The only significant difference was the lower rate of regional osteoporosis seen in the radiographs of aspirin group. Mean age was significantly higher in the patients with CRPS. Also, comminuted distal radius fractures (A3-type) were significantly more common in the patients with CRPS. Administration of aspirin in patients with a distal radius fracture was associated with a lower incidence of CRPS, but, not statistically significant. Further investigations needs to be done with a larger sample size, longer follow-up period and multi-center design.

Complex regional pain syndrome in distal radius fractures: How to implement changes to reduce incidence and facilitate early management

STUDY DESIGN

Implementation paper.

INTRODUCTION

Complex regional pain syndrome (CRPS) is relatively a common condition in the distal radius fracture (DRF) population with the effects resulting in many sufferers experiencing persistent pain and impairment 2 to 6 years after onset. Prevention is desirable as there is no known proven cure.

PURPOSE OF THE STUDY

This study demonstrates how knowledge about CRPS and its prevention generated through iterative studies can be translated into practice in the workplace and how an interdisciplinary community of practice with therapists at the core can effect change.

METHODS

A series of practice changes were introduced including a patient information leaflet, a local gold standard for care of DRF, education for staff regarding risk factors and early warning signs of CRPS, and simple patient and staff visual aids.

RESULTS

The incidence of CRPS was reduced from 25% to 1% in the DRF population at the study site, and collaborative care pathways were ingrained onto the working culture.

DISCUSSION

The process of learning together fostered the development of an interdisciplinary team with therapists acting as CRPS champions. Interdisciplinary team reflective practice facilitated simple but effective interventions, which reduced the incidence of CRPS in DRF population locally. It is not yet known whether this is transferable.

CONCLUSIONS

Simple interventions can have a significant impact on the incidence of CRPS in a community of practice where a culture of team reflection and shared learning occurs.

A case report of wireless peripheral nerve stimulation for complex regional pain syndrome type-I of the upper extremity: 1 year follow up

Background

Complex regional pain syndrome (CRPS) is a chronic disabling painful disorder with limited options to achieve therapeutic relief. CRPS type I which follows trauma, may not show obvious damage to the nervous structures and remains dubious in its pathophysiology and also its response to conservative treatment or interventional pain management is elusive. Spinal cord and dorsal root ganglion stimulation (SCS, DRGS) provide good relief, mainly for causalgia or CRPS I of lower extremities but not very encouraging for upper extremity CRPS I. we reported earlier, a case of CRPS I of right arm treated successfully by wireless peripheral nerve stimulation (WPNS) with short term follow up. Here we present 1-year follow-up of this patient.

Objective

To present the first case of WPNS for CRPS I with a year follow up. The patient had minimally invasive peripheral nerve stimulation (PNS), without implantable pulse generator (IPG) or its accessories.

Case report

This was a case of refractory CRPS I after blunt trauma to the right forearm of a young female. She underwent placement of two Stimwave electrodes (Leads: FR4A-RCV-A0 with tines, Generation 1 and FR4A-RCV-B0 with tines, Generation 1) in her forearm under intraoperative electrophysiological and ultrasound guidance along radial and median nerves. This WPNS required no IPG. At high frequency (HF) stimulation (HF 10 kHz/32 μs, 2.0 mA), patient had shown remarkable relief in pain, allodynia and temperature impairment. At 5 months she started driving without opioid consumption, while allodynia disappeared. At 1 year follow up she was relieved of pain [visual analogue scale (VAS) score of 4 from 7] and Kapanji Index (Score) improved to 7–8. Both hands look similar in color and temperature. She never made unscheduled visits to the clinic or visited emergency room for any complications related to the WPNS.

Conclusions

CRPS I involving upper extremity remain difficult to manage with conventional SCS or DRGS because of equipment related adverse events. Minimally invasive WPNS in this case had shown consistent relief without any complications or side effects related to the wireless technology or the technique at the end of 1 year.

Implications

This is the first case illustration of WPNS for CRPS I, successfully treated and followed up for 1 year.

Fibromyalgia as a Predictor of Complex Regional Pain Syndrome After Distal Radius Fracture

Background: Complex regional pain syndrome (CRPS) can be a devastating complication following extremity injury, but risk factors are not well understood. The purpose of this study was to investigate the association between fibromyalgia and the development of CRPS after distal radius fracture. Methods: The PearlDiver Medicare database was queried using International Classification of Diseases, 9th Revision (ICD-9) and Current Procedural Terminology (CPT) codes for diagnoses and treatments of distal radius fractures. Patients were separated into fibromyalgia and control cohorts, and the prevalence of CRPS was measured at 3, 6, 9, and 12 months from the date of injury or procedure. Demographic factors, treatment modality, and comorbid conditions were analyzed by multivariable logistic regression to reduce confounding and identify additional risk factors. Results: Database queries yielded 853 186 patients diagnosed or treated for distal radius fracture, with 6% having previous diagnosis of fibromyalgia. The prevalence of CRPS following distal radius fracture was increased at 3, 6, 9, and 12 months in the fibromyalgia cohort compared with the control c, with a 1-year incidence of 0.51% compared with 0.20% (odds ratio [OR], 2.54, P < .001). Multivariable logistic regression supported the association, with estimated OR of 2.0 (P < .001). In addition, female gender, surgical or manipulative treatment, and anxiety were positively associated with CRPS, and age >65, diabetes, and heart failure were negatively associated. Conclusions: While the basis of the association between fibromyalgia and CRPS is unknown, our data suggest that it could serve as a useful predictor of CRPS risk, promoting increased vigilance for CRPS symptoms and earlier recognition and treatment, thereby improving patient outcomes.

Incidence of and Risk Factors for Complex Regional Pain Syndrome Type 1 after Surgery for Distal Radius Fractures: A Population-based Study

This study aimed to evaluate the incidence rates of and risk factors for complex regional pain syndrome type 1 (CRPS-1) after surgery for distal radius fractures (DRFs). Using data from January 2007 to December 2014, we analysed the data from the Korean Health Insurance Review and Assessment (HIRA) service. After extracting the data of patients aged ≥18 years whose diagnostic and operation codes for DRFs were entered into the HIRA database, we analysed the incidence rates of and risk factors for CRPS-1. From 2007 to 2014, 172,194 DRFs were treated surgically. Within 1 year postoperatively, 1,103 CRPS-1 cases were diagnosed, with an incidence of 0.64%. On univariate and multivariate analyses, the risk factors that significantly correlated with the incidence of CRPS-1 included female sex, rheumatoid arthritis, open reduction, open fracture, and accompanying ulnar fracture, whereas old age, psychiatric disease, and external fixation were not statistically significant. The incidence of CRPS-1 after surgery for DRF was very low (0.64%) in South Korea. Careful monitoring is necessary for patients with complex fractures and rheumatoid arthritis who are at increased risk of developing CRPS-1.

The Rodent Tibia Fracture Model: A Critical Review and Comparison With the Complex Regional Pain Syndrome Literature

Distal limb fracture is the most common cause of complex regional pain syndrome (CRPS), thus the rodent tibia fracture model (TFM) was developed to study CRPS pathogenesis. This comprehensive review summarizes the published TFM research and compares these experimental results with the CRPS literature. The TFM generated spontaneous and evoked pain behaviors, inflammatory symptoms (edema, warmth), and trophic changes (skin thickening, osteoporosis) resembling symptoms in early CRPS. Neuropeptides, inflammatory cytokines, and nerve growth factor (NGF) have been linked to pain behaviors, inflammation, and trophic changes in the TFM model and proliferating keratinocytes were identified as the primary source of cutaneous cytokines and NGF. Tibia fracture also activated spinal glia and upregulated spinal neuropeptide, cytokine, and NGF expression, and in the brain it changed dendritic architecture. B cell-expressed immunoglobulin M antibodies also contributed to pain behavior, indicating a role for adaptive immunity. These results modeled many findings in early CRPS, but significant differences were also noted.

PERSPECTIVE

Multiple neuroimmune signaling mechanisms contribute to the pain, inflammation, and trophic changes observed in the injured limb of the rodent TFM. This model replicates many of the symptoms, signs, and pathophysiology of early CRPS, but most post-fracture changes resolve within 5 months and may not contribute to perpetuating chronic CRPS.

Wireless peripheral nerve stimulation for complex regional pain syndrome type I of the upper extremity: a case illustration introducing a novel technology

Background

Complex regional pain syndrome (CRPS) is a debilitating painful disorder, cryptic in its pathophysiology and refractory condition with limited therapeutic options. Type I CRPS with its variable relationship to trauma has often no discernible fractures or nerve injuries and remains enigmatic in its response to conservative treatment as well as the other limited interventional therapies. Neuromodulation in the form of spinal cord and dorsal root ganglion stimulation (SCS, DRGS) has shown encouraging results, especially of causalgia or CRPS I of lower extremities. Upper extremity CRPS I is far more difficult.

Objective

To report a case of upper extremity CRPS I treated by wireless peripheral nerve stimulation (WPNS) for its unique features and minimally invasive technique. The system does not involve implantation of battery or its connections.

Case report

A 47 year old female patient presented with refractory CRPS I following a blunt trauma to her right forearm. As interventional treatment in the form of local anesthetics (Anesthesia of peripheral branches of radial nerve) and combined infusions of ketamine/lidocaine failed to provide any significant relief she opted for WPNS treatment. Based on the topographic distribution, two electrodes (Stimwave Leads: FR4A-RCV-A0 with tines, Generation 1 and FR4A-RCV-B0 with tines, Generation 1), were placed along the course of radial and median nerves under ultrasonography monitoring and guided by intraoperative stimulation. This procedure did not involve implantation of extension cables or the power source. At a frequency of 60 Hz and 300 μs the stimulation induced paresthesia along the distribution of the nerves. Therapeutic relief was observed with high frequency (HF) stimulation (HF 10 kHz/32 μs, 2.0 mA) reducing her pain from a visual analogue scale (VAS) score of 7–4 postoperatively. Three HF stimulations programs were provided at the time of discharge, as she improved in her sensory impairment to touch, pressure and temperature at her first follow up visit. At 5-months she was able to drive, did not require opioids and allodynia disappeared.

Conclusions

In a case with difficult CRPS I involving upper extremity, a minimally invasive WPNS of radial and median nerves provided good symptomatic relief. The procedure was tolerated well and both electrodes remained in place without any adverse events.

Implications

In view of the very limited options currently available to manage CRPS, WPNS can be a promising therapeutic modality.

Complex regional pain syndrome acute care pathways in England: Do they exist and what do they look like?

Introduction

Complex Regional Pain Syndrome is a condition with a high degree of morbidity and health costs to the National Health Service (NHS), characterised by persistent pain, sensory, motor, trophic and autonomic signs and symptoms. The British Orthopaedic Association (BOA) and the Royal College of Physicians (RCP) have recommended treatment guidelines and care pathways for the management of acute Complex Regional Pain Syndrome. The objective of this scoping exercise was to use Freedom of Information (FOI) requests to ascertain whether NHS Trusts in England had such pathways and what they looked like.

Methods

FOI requests were sent to 126 English NHS Trusts on 9 March 2017 on behalf of the Complex Regional Pain Syndrome Clinical and Research Network UK, asking: “What does your acute Complex Regional Pain Care Syndrome pathway look like?”

Results

Replies were received by 95 NHS Trusts and of these 84 had relevant services but (82%) had no pathway or agreed initial management.

Conclusions

It appears to be common for no acute care pathway to exist for CRPS in NHS Trusts in England despite it being a domain in BOA national guidelines. The Royal College of Physicians guidelines also recommend integrated MDT care. Consequentially, BOA and Royal College of Physicians standards in acute CRPS management are not yet being followed in most acute NHS Trusts in England providing trauma care. Where there is a pathway agreed, it is rarely integrated and truly multidisciplinary.

[Complex pain regional syndrome after distal radius fractures]

Complex regional pain syndrome (CPRS) greatly affects the outcomes of distal radius fractures in terms of functional recovery, time away from work and patient satisfaction. The diagnosis is sometimes difficult to make in the immediate post-injury period. The disproportionate nature of the pain in the absence of differential diagnoses and the presence of a pain-free interval should arouse suspicion. The natural history consists of spontaneous improvement except in some refractory forms. The treatment is multidisciplinary combining a physician specializing in pain, therapist and psychologist coordinated by the surgeon who must not abandon the patient. Treatment aims to improve the patient's comfort and quality of life. Recent treatment approaches aimed at improving cortical reorganization have demonstrated their effectiveness. Surgery has to be considered even in the acute phase to address any causes of pain that can be resolved and address secondary stiffness. Significant progress has to be made in our understanding of the pathogenesis of CPRS to improve treatment and shift this condition to a regional pain syndrome.

[Complex regional pain syndrome following distal fractures of the radius : Epidemiology, pathophysiological models, diagnostics and therapy]

The complex regional pain syndrome (CRPS) still represents an incompletely etiologically understood complication following fractures of the distal radius. The incidence of CRPS following fractures of the distal radius varies between 1 % and 37 %. Pathophysiologically, a complex interaction of inflammatory, somatosensory, motor and autonomic changes is suspected, leading to a persistent maladaptive response and sensitization of the central and peripheral nervous systems with development of the corresponding symptoms. Decisive for the diagnostics are a detailed patient medical history and a clinical hand surgical, neurological and pain-related examination with confirmation of the Budapest criteria. Among the types of apparatus used for diagnostics, 3‑phase bone scintigraphy and temperature measurement have a certain importance. A multimodal therapy started as early as possible is the most promising approach for successful treatment. As part of a multimodal rehabilitation the main focus of therapy lies on pain relief and functional aspects.

Can we reduce the incidence of complex regional pain syndrome type I in distal radius fractures? The Liverpool experience

Introduction

Complex regional pain syndrome is a multifaceted condition, which is relatively common after distal radius fracture.

Method

A series of audits and service evaluations were conducted from 2004 to 2013 to investigate the incidence of complex regional pain syndrome type I and any correlation to tight, restrictive, over-flexed casts. Simple subsequent clinical and patient management changes were implemented and impact re-evaluated.

Results

These audits have contributed to organisational learning and a subsequent reduction in the incidence of complex regional pain syndrome type I in non-operatively managed distal radius fracture from 25%, in keeping with expected incidence in the relevant literature, to a rare event (<1%).

Conclusion

The authors suggest that careful attention to the prevention of complex regional pain syndrome through staff and patient awareness, vigilance for warning signs and minor modifications to the traditional management of distal radius fractures can significantly reduce the incidence of complex regional pain syndrome type I after distal radius fracture.

Management of complications of distal radius fractures

Treating a fracture of the distal radius may require the surgeon to make a difficult decision between surgical treatment and nonsurgical management. The use of surgical fixation has recently increased because of complications associated with conservative treatment. However, conservative action may be necessary depending on certain patient factors. The treating surgeon must be aware of the possible complications associated with distal radius fracture treatments to prevent their occurrence. Prevention can be achieved with a proper understanding of the mechanism of these complications. This article discusses the most recent evidence on how to manage and prevent complications following a fracture of the distal radius.

Factors associated with complex regional pain syndrome type I in patients with surgically treated distal radius fracture

PURPOSE

Wrist fracture is considered a typical initiating trauma for complex regional pain syndrome type I (CRPS I). However, few studies have comprehensively evaluated factors associated with the occurrence of CRPS I after the surgical treatment of a distal radius fracture (DRF). This study evaluates the factors influencing the occurrence of CRPS I after the surgical treatment of a DRF.

METHODS

A total of 477 patients with a DRF who had been treated surgically were enrolled in this prospective observational study. Patients were followed for 6 months after surgery, and CRPS I was diagnosed using the Budapest diagnostic criteria for research. The factors assessed for the development of CPRS I were age, gender, the body mass index, the type of fracture, the energy of trauma, the number of trial reductions, the type of surgery, and the duration of immobilization. A multivariate logistic regression analysis was conducted to identify independent predictors of the occurrence of CRPS I.

RESULTS

Among the 477 patients, 42 (8.8 %) satisfied the Budapest criteria for CRPS I within 6 months of surgery. Female patients developed CRPS I more frequently, and the patients who developed CRPS I were older and more likely to sustain a high energy injury or have a comminuted fracture. According to the multivariate analysis, female patients and those with a high energy trauma or severe fracture type were significantly more likely to develop CRPS I (p = 0.02, 0.01, and 0.01, respectively).

CONCLUSIONS

High energy injuries, severe fractures, and the female gender contribute to the development of CRPS I after the surgical treatment of DRF. The results have important implications for physicians who wish to identify patients at high risk for CRPS I after operative fixation for DRF and instigate treatment accordingly.

Complex regional pain syndrome type 1 in a pediatric patient: Case report

Complex regional pain syndrome type 1 is one of the causes of morbidity of childhood which is also named reflex symphathetic dystrophia. The syndrome is characterized with regional pain and vasomotor, sudomotor and sensory changes in the distal parts of the extremities involved. Complex regional pain syndrome type 1 shows difference in children in terms of clinical picture and imaging methods compared to adults. The most important point is that the prognosis is generally better in children if early diagnosis and treatment is provided. On the other hand, causes including presence of psychological factors or less contribution of imaging methods in children lead to delayed diagnosis or erroneous diagnosis. In this article, a 10 year-old male patient who was diagnosed with complex regional pain syndrome type 1 was described. Thus, we aimed to remind clinicians that this syndrome should also be kept in mind in the differential diagnosis of pain in children.

Complex regional pain syndrome type I: incidence and risk factors in patients with fracture of the distal radius

OBJECTIVE

To examine the incidence and predictors of complex regional pain syndrome type I (CRPS I) after fracture of the distal radius.

DESIGN

Prospective study.

SETTING

University hospital.

PARTICIPANTS

A consecutive sample of patients (N=90) with fracture of the distal radius treated by closed reduction and casting.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Occurrence of CRPS I, occurrence of pain, wrist and hand range of motion, radiographic measures, Patient-Rated Wrist Evaluation, Hospital Anxiety and Depression Scale, and Medical Outcomes Study 36-Item Short-Form Health Survey at baseline and 1, 3, 6, and 9 months follow-up.

RESULTS

CRPS I occurred in 29 patients (32.2%) with a mean delay ± SD of 21.7±23.7 days from cast removal. Univariate analyses found significant differences between patients with CRPS I and patients without CRPS I at baseline for sex (P=.021), socioeconomic level (P=.023), type of trauma (P=.05), pain at rest and activity (P=.006 and P<.001, respectively), wrist dorsiflexion and pronation (P=.002 and P=.001, respectively), finger flexion (P=.047), thumb opposition (P=.002), function of the hand (P<.001), and physical quality of life (QOL) (P=.013). Logistic regression showed that risk for CRPS I was higher in cases of women (odds ratio [OR]=5.774; 95% confidence interval [CI], 1.391-23.966), medium and low energy trauma patients (OR=7.718; 95% CI, 1.136-52.44), patients with a Medical Outcomes Study 36-Item Short-Form Health Survey physical functioning score <40 (OR=4.931; 95% CI, 1.428-17.025), and patients with Patient-Rated Wrist Evaluation pain subscale score >16 (OR=12.192; 95% CI, 4.484-43.478).

CONCLUSIONS

CRPS I occurs frequently during the third and fourth week after cast removal, especially in women who report severe pain and impairment of physical QOL. Additional prospective studies are required to verify these findings in comminuted and operated fractures of the distal radius.

Complex regional pain syndrome: a review

Complex regional pain syndrome, formally known as reflex sympathetic dystrophy, is a poorly understood condition that describes a collection of clinical symptoms and signs occurring in the peripheries most commonly after trauma. Pain is the main problem. It is generally out of proportion to the degree of injury and can be unresponsive to narcotics. In addition joint stiffness, temperature and colour changes, and swelling occur. The diagnosis and treatment are challenging for any clinician and a multidisciplinary approach is often necessary with physiotherapy, occupational therapy, and the pain team. The hand surgeon is involved for two reasons, firstly as the upper limb is the most frequently involved, and secondly because the condition may be a complication of the patient's surgery and result in a much prolonged recovery. This review elucidates the recent advances in the knowledge of the aetiology, classification and treatment of this fascinating condition.

Complex regional pain syndrome type I as a consequence of trauma or surgery to upper extremity: management with intravenous regional anaesthesia, using lidocaine and methyloprednisolone

Complex regional pain syndrome type I (CRPS-I) is a known complication after surgery or trauma to the upper extremity and is difficult to treat. A simple and easily tolerated method of treatment that includes intravenous regional anaesthetic block with lidocaine and methyloprednisolone is presented. One hundred and sixty-eight patients with CRPS-I of the upper extremity were treated in a 5-year period. At the end of treatment 88% of the patients reported minimal or no pain. After a mean follow-up of 5 years (range 28 months to 7 years) complete absence of pain was reported by 92% of patients. The symptoms of the acute phase of the syndrome were reversed. Early recognition and prompt initiation of treatment is very important for the course of the disease as symptoms can be reversible when treatment starts early. Permanent results with a functional upper extremity and very satisfactory pain relief can be anticipated.

Complex regional pain syndrome

Complex regional pain syndrome (CRPS) previously known as reflex sympathetic dystrophy is a chronic neurological disorder involving the limbs characterized by disabling pain, swelling, vasomotor instability, sudomotor abnormality, and impairment of motor function. CRPS is not uncommon after hand surgery and may complicate post-operative care. There is no specific diagnostic test for CRPS and the diagnosis is based on history, clinical examination, and supportive laboratory findings. Recent modifications to diagnostic criteria have enabled clinicians to diagnose this disease more consistently. This review gives a synopsis of CRPS and discusses the diagnosis, pathophysiology, and treatment options based on the limited evidence in the literature.

Complications of distal radius fractures

Fractures occur at the distal end of the radius more frequently than at any other location. The reported complication rates of distal radius fractures in the literature vary from 6% to 80%. Complications may occur from the fracture or its treatment. This article reviews complications caused by distal radius fractures and their treatment. Complications are divided chronologically into immediate, early (less than 6 weeks), and late (greater than 6 weeks).

Is there an association between psychological factors and the Complex Regional Pain Syndrome type 1 (CRPS1) in adults? A systematic review

Complex Regional Pain Syndrome type 1 (CRPS1) is a complication after trauma or surgery. Its pathophysiology is still a matter of debate, and psychological factors have been suggested to play a role, although their influence is unclear. The aim of this study was to investigate the evidence for the influence of psychological factors on the onset and maintenance of CRPS1 in adults. In a systematic review, articles were selected using Cochrane, Pubmed/Medline, Psychinfo, and Cinahl since 1980. Only original articles and empirical studies were included. Based on these selection criteria, 31 articles were identified. Studies were evaluated and weighted using a quality assessment instrument. The few prospective studies do not report a relationship between CRPS1 and depression, anxiety, neuroticism, or anger. The results of the retrospective/cross-sectional studies yield contradictory results regarding psychological problems in patients with CRPS1. A majority show no association, and studies with a higher methodological quality lean to a conclusion of no relationship between psychological factors and CRPS1. The majority of included studies (N=24; 77%) had only a poor to moderate methodological quality. Although many patients with CRPS1 are stigmatized as being psychologically different, this literature review identified no relationship between CRPS1 and several psychological factors. Only life events seemed to be associated with CRPS1: patients who experienced more life events appeared to have a greater chance of developing CRPS1. More studies with greater methodological quality and more participants should be performed on the association between psychological factors and the development and course of CRPS1.

Treatment of early complex regional pain syndrome type 1 by a combination of mannitol and dexamethasone

A total of 75 patients, 68 women (91%) and seven men (9%), with a mean age of 58 (range 38-82) years with early Complex Regional Pain Syndrome Type 1 (CRPS Type 1), present for less than 4 months, were given in-patient treatment with 10% mannitol 2 x 250 ml per day and 8 mg dexamethasone per day for 1 week. Measurements assessed included the pain, the range of finger movements, grip strength and our own clinical severity scoring system for CRPS Type 1 (CRPS score). The results were assessed at 1 week and, finally, at a mean of 9 (range 8-12) months. At 1-week assessment, all variables decreased significantly: pain from a mean Visual Analogue Scale (VAS) of 6.7 to 2.3, loss of finger flexion (6-0.3 cm) and the CRPS score (7.6-2.2 points). Total grip strength did not improve. At the final assessment of 70 patients, the VAS score was a mean of 1.8, loss of finger flexion a mean of 0.1 cm, the CRPS score was a mean of 1.6 and grip strength a mean of 34% of the strength of the unaffected hand. All these variables showed statistically significant improvement.

Complications of distal radius fractures

Fractures occur at the distal end of the radius more frequently than at any other location. The reported complication rates of distal radius fractures in the literature vary from 6% to 80%. Complications may occur from the fracture or its treatment. This article reviews complications caused by distal radius fractures and their treatment. Complications are divided chronologically in to immediate, early (less than 6 weeks), and late (greater than 6 weeks).

Complex regional pain syndrome type 1 after fractures of the distal radius: a prospective study of the role of psychological factors

A prospective study was designed to investigate the question "Do patients who develop Complex Regional Pain Syndrome Type 1 (CRPS Type 1) after fracture of the distal radius display different psychological behaviour patterns and/or are more depressive than those who recover uneventfully after this fracture?" Sixty-two patients of mean age 56 years with displaced distal radius fractures were operated on by closed reduction and percutaneous fixation with K-wires. All these patients were examined psychologically on the day after the operation. A series of standardized, self-administered questionnaires was used to assess personality and depression. Fifty of the 62 patients were reassessed at 2 months for symptoms and signs of CRPS Type 1 and a diagnosis of this condition made on clinical grounds. Nine patients (18%) were diagnosed as having CRPS Type 1. There were no significant differences in scores on any of the personality and depression scales between CRPS Type 1 and non-CRPS Type 1 patients. Therefore, patients who eventually developed CRPS Type 1 after radial forearm fracture had neither a unique psychological pattern nor displayed more symptoms of depression than those who recovered uneventfully.