Algodystrophy

Early changes in bone density, microarchitecture, bone resorption, and inflammation predict the clinical outcome 12 weeks after conservatively treated distal radius fractures: an exploratory study

Fracture healing is an active process with early changes in bone and inflammation. We performed an exploratory study evaluating the association between early changes in densitometric, structural, biomechanical, and biochemical bone parameters during the first weeks of fracture healing and wrist-specific pain and disability at 12 weeks in postmenopausal women with a conservatively treated distal radius fracture. Eighteen patients (aged 64 ± 8 years) were evaluated at 1 to 2 and 3 to 4 weeks postfracture, using high-resolution peripheral quantitative computed tomography (HR-pQCT), micro-finite element analysis, serum procollagen type-I N-terminal propeptide (P1NP), carboxy-terminal telopeptide of type I collagen (ICTP), and high-sensitive C-reactive protein (hsCRP). After 12 weeks, patients rated their pain and disability using Patient Rated Wrist Evaluation (PRWE) questionnaire. Additionally, Quick Disability of the Arm Shoulder and Hand (QuickDASH) questionnaire and active wrist range of motion was evaluated. Linear regression models were used to study the relationship between changes in bone parameters and in hsCRP from visit 1 to 2 and PRWE score after 12 weeks. A lower PRWE outcome, indicating better outcome, was significantly related to an early increase in trabecular bone mineral density (BMD) (β -0.96 [95% CI -1.75 to -0.16], R(2)  = 0.37), in torsional stiffness (-0.14 [-0.28 to -0.004], R(2)  = 0.31), and to an early decrease in trabecular separation (209 [15 to 402], R(2)  = 0.33) and in ICTP (12.1 [0.0 to 24.1], R(2)  = 0.34). Similar results were found for QuickDASH. Higher total dorsal and palmar flexion range of motion was significantly related to early increase in hsCRP (9.62 [3.90 to 15.34], R(2)  = 0.52). This exploratory study indicates that the assessment of early changes in trabecular BMD, trabecular separation, calculated torsional stiffness, bone resorption marker ICTP, and hsCRP after a distal radius fracture provides valuable information regarding the 12-week clinical outcome in terms of pain, disability, and range of motion and validates its use in studies on the process of early fracture healing. © 2014 American Society for Bone and Mineral Research.

Efficacy of salmon calcitonin in complex regional pain syndrome (type 1) in addition to physical therapy

The aim of the study was to assess the efficacy of salmon calcitonin, which was suggested as effective in the treatment of complex regional pain syndrome type 1 (CRPS 1). Patients who had suffered trauma to their upper extremities and developed CRPS 1 were included into this randomised, controlled single-blind study. The diagnosis was made according to the clinical examination and scintigraphy. The evaluation parameters were: pain [visual analogue scale (VAS)], the angle of dorsiflexion (DF) and palmar flexion (PF) of the wrist, distance between the fingertip and distal palmar crease (FT-DPC), allodynia, hyperalgesia and trophic changes. One group received paracetamol 1500 m/day and the other group salmon calcitonin 200 IU/day for 2 months. All of the patients participated in a physical therapy and exercise programme. A total of 35 patients were divided into two groups, who were found to be similar for age, body mass index, period of trauma, period of rest in a plaster splint or bandage, the duration of symptoms, VAS, DF and PF angle, FT-DPC, presence of allodynia, hyperalgesia and trophic changes (p>0.05). The control examination showed similar results for allodynia, hyperalgesia and trophic changes, whereas remarkable improvement was observed in the rest of the parameters within groups. On the other hand, between the two groups there was no significant difference in any of the parameters (p>0.05) This randomised, single-blind study showed that all of the patients with acute CRPS 1 in their upper extremities after trauma, who were treated with either paracetamol or calcitonin along with physical therapy, recovered in all parameters significantly, but without any difference between groups. We can conclude that calcitonin does not make any favourable contribution in the treatment of patients with acute CRPS 1; physical therapy combined with only a simple analgesic is an efficient means of therapy.

The fasciitis-panniculitis syndrome presenting as complex regional pain syndrome type 1: report of a case

A 28-year-old man presented with a clinical picture suggestive of complex regional pain syndrome type I following a blow to the thenar eminence and thumb. Symptoms, including swelling of the hand and distal forearm, progressed until an amputation was carried out to rid the patient of an unendurable painful and nonfunctioning wrist and hand. The histologic evaluation of the amputation specimen showed: 1) dermal edema, perivascular dermatitis, and epidermal hyperkeratosis; 2) subcutaneous chronic inflammation with subtotal replacement of the adipose lobules by fibrous tissue associated with thickening of the muscular fascia, implying the fasciitis-panniculitis reaction pattern; 3) atrophy, degeneration, necrosis, and focal calcifications of the skeletal muscles; 4) phlebosclerosis, phlebectasias and lymphocytic arteritis; and 5) increased cortical porosity of the bones. It seems that the pathogenetic process underlying the fasciitis-panniculitis syndrome may rarely manifest as a complex regional pain syndrome-like disorder.