Complex Regional Pain Syndrome

Definitions

CRPS Type 1

  • Diffuse abnormal reaction to a noxious event or immobilization leading to pain, vasomotor changes, and joint stiffness
  • More relevant to Orthopaedic Surgery

CRPS Type 2

  • Causalgia – initiated by injury or affliction of a particular nerve

Risk Factors

  • Females
  • Wrist fractures
  • 40-50 years

Pathophysiology

  • Tissue trauma stimulates mast cells to release tryptase
  • Immobilization causes release and accumulation of free radicals
  • Constrictive bandages exacerbate edema formation
  • Genetic predisposition

Clinical Features - STAMPP

  • Sensory: Hyperesthesia, Hyperalgesia, Allodynia
  • Trophic: Hair thinning, sweating, brittle nails, osteopenia
  • Autonomic: Edema, temperature asymmetry, mottled appearance
  • Motor: Poor ROM, weakness
  • Pain: Disproportionate, constant, burning, poorly defined
  • Psyche: Associated depression – cause or effect?

Biphasic Condition

  • Initially characterized by hot, edematous skin
  • Later progresses to mottled, cool skin with trophic changes

Natural History

  • May resolve with treatment
  • If left untreated, can worsen and lead to permanent disability

Diagnosis

Clinical

  • Primarily a clinical diagnosis
  • High index of suspicion required
  • Rule out underlying nerve injury (CRPS Type 2)
  • CRPS will almost always show some radiographic changes

Investigations

  • X-ray: Diffuse osteopenia (late feature)
  • Bone scan:
    • Early stages: Hot uptake
    • Late stages: May be normal

Management

Multidisciplinary Approach

Prevention

  • Awareness of the condition
  • Vitamin C (Zollinger et al JBJS 2010 RCT)
  • Early ROM exercises
  • Elevation
  • Early recognition

Remove Perpetuating Stimuli

  • Casts, splints, or immobilization

Referral to Specialists

  • Hand Therapy (Most important part of treatment)
    • Desensitization
    • Mirror therapy
    • TENS
    • Acupuncture
    • Splinting
    • ROM exercises
    • Counseling & Support
    • Massage
    • Hot-cold therapy
    • Functional restoration
  • Pain Clinic
    • TENS
    • Acupuncture
    • Pharmacologic sympathetic blockades
    • Spinal cord stimulation

Medications

  • Tricyclics (e.g., Amitriptyline – beware side effects)
  • Anti-convulsants (e.g., Gabapentin)
  • Vitamin C (Prophylactic action by reducing free radicals)

Surgical Management

  • Only if a clear inciting issue exists (e.g., nerve compression, neuroma)
  • Sympathectomy is unreliable
  • Surgery generally worsens CRPS and should be avoided

Overall Approach

  • Multidisciplinary: Therapy, counseling, pharmacology
  • Multimodal treatment for best outcomes
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