Reflex sympathetic dystrophy: misdiagnosis in patients with dysfunctional postures of the upper extremity

Outcomes of Carpal Tunnel Release in Complex Regional Pain Syndrome/Reflex Sympathetic Dystrophy/Sudeck Disease Patients

BACKGROUND

The clinical features of classic carpal tunnel syndrome are well known. However, some patients who display atypical symptoms and signs of pain and dysesthesias in the hand, worsening of symptoms at night, and above all, inability to make a full fist, respond equally well to carpal tunnel release. This same clinical picture was shared by some patients labeled as having complex regional pain syndrome. Because of the poor outcome of complex regional pain syndrome patients with current regimens, the authors tested the hypothesis that carpal tunnel release could be effective on them. The purpose of this article is to report the outcome of carpal tunnel release in complex regional pain syndrome patients who presented the above signs and symptoms.

METHODS

Fifty-three patients with an average age of 55 years presenting the above cluster of symptoms were operated on. All were unilateral cases, had sustained trauma, and were treated for complex regional pain syndrome before referral for an average of 16 months. All patients underwent carpal tunnel release.

RESULTS

At a minimum of 6 months' follow-up, pain dropped 7.5 points on a numerical rating scale of 0 to 10 ( p < 0.001). Disabilities of the Arm, Shoulder and Hand scoring fell from 82 to 17 ( p < 0.001). Six patients had an unsatisfactory result.

CONCLUSIONS

Some patients with complex regional pain syndrome may respond successfully to a carpal tunnel release operation. Recognition of this possibility is crucial, as the symptoms and signs might lead the clinician away from the proper diagnosis and treatment.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, IV.

Posttraumatic Complex Regional Pain Syndrome and Related Comorbidities

The complex regional pain syndrome (CRPS) is a neuropathic disorder, often precipitated by a fracture, injury of the soft tissue or a surgical procedure followed by extended immobilization. Clinical signs and symptoms of this syndrome include abnormalities of pain processing (mechanical and thermal allodynia, hyperalgesia and hyperpathia), skin changes regarding local temperature and the presence of erythema, cyanosis or mottled appearance, neurogenic edema, motor and trophic disorders. The CRPS has three evolutionary stages-acute, dystrophic and atrophic, and it is divided into two types, reflecting the absence or presence of nerve damage. The patient presented in this study was a female with a history of metabolic syndrome, diagnosed with polyarticular chronic gout, which despite the specific drug treatment administered, had multiple predisposing factors for the development of CRPS consecutive to the fracture of both bones of the right forearm. It is evident that the recovery period after injury is slightly different in each individual and depends on the severity of the injury and patient factors such as age, general condition and the presence of other comorbidities. The delay between the onset of symptoms and her presentation to the physician, conferred a poor prognosis for the developing pathology, with important functional and motor impairment.

The psychoflexed hand: new perspectives in diagnosis, classification and treatment

The psychoflexed hand is a rare clinical condition characterized by fixed finger contractures undetermined by organic etiology, often associated with a psychiatric pathology. We report a series of 20 patients (nine males and 11 females, mean aged 56.2 years). We have introduced a new classification of the various possible patterns of finger deformities: 1) Type 1: prevalent flexion contracture at the metacarpophalangeal (MCP) and proximal interphalangeal (PIP) joints of the last two or three fingers; the thumb and the index are not affected; 2) type 2: prevalent flexion contracture at the PIP and distal interphalangeal (DIP) joints of the last two or three fingers; 3) type 3: flexion contracture of all the long fingers; 4) type 4: flexion contracture of all the fingers of the hand, including the thumb (clenched fist syndrome); 5) type 5: isolated flexus-adductus thumb (the long fingers are not affected); 6) type 6: flexion of digits associated with flexion contractures of other joints of the upper extremity. The treatment was conservative in 14 patients with recent deformities and surgical in six patients. Both forms of treatment were followed by a rigorous rehabilitation program, mostly based on home self-rehabilitation. The correction of the deformities was obtained in all cases and maintained over time.

Factitious disorders encountered in patients with the diagnosis of reflex sympathetic dystrophy

Reflex sympathetic dystrophy (RSD) may be a misdiagnosis or at least not descriptive enough in patients with atypical hand posture and atypical edema. Seven patients with the previous diagnosis of RSD were investigated further because of inconsistent clinical picture with the underlying pathology and bizarre course of the disease. Four patients had clenched fist and three had factitious edema. These seven patients underwent psychological examination, and MMPI was applied to all. In two of these no psychological disorder was obtained according to DSM-IV. One patient could not adapt to MMPI. In two anxiety disorders, in one depression, and in one patient conversion disorder was diagnosed. We suggest that these patients are not motivated enough to improve their conditions and expectations of such patients may show some differences depending on the environment.