This Issue's Rounds Question -
Please tell us:
You have just placed a patient in full balanced traction and it has been a while since those skills have been requested from you. List the potential complications that may occur in patients in traction.

(responses to be published in next issue)

In the last issue of Body Cast, Rounds asked: What is complex regional pain syndrome (CRPS)?
The following responses were received:

From Neil Lockyer and Ed Clancey:
It is a nervous system problem, previously referred to as reflex sympathetic dystrophy or RSD. The syndrome was first described after the U.S. Civil War when soldiers continued to have pain after their wounds had healed.

It is an uncommon chronic condition that usually affects the arm or leg. Experiencing intense burning or aching along with swelling, skin discolouration, temperature and abnormal sweating in the affected area.

Causes
The cause isn't clearly understood, but it is thought to be of two types:

1. occurs after an illness or injury that didn't directly damage the nerves (RSD)
2. follows a distinct nerve injury, often referred to as Causalgia.

Signs and symptoms
The main symptom is intense pain, often described as burning, skin sensitivity with tenderness, thin and shiny. There is joint stiffness and muscle weakness and atrophy, and decreased ability to move body part.

There are three stages:

1. severe pain, swelling, and sensitivity to touch or to cold. Lasts about one to three months
2. changes to the colour and texture of skin, swelling spreads with increased stiffness
3. severe damage is noted, irreversible skin damage, muscle atrophy and contractures.

Treatment
If treatment is started in the early stages of injury, dramatic improvement can be obtained. This includes:

1. medications, nonsteroidal anti-inflammatory drugs (NSAIDS),
prescription drugs such as antidepressants used to treat pain
that originates from nerve damage (neuropathic pain)
2. applying heat and cold 3. physical therapy
4. sympathetic nerve-blocking medication
5. transcutaneous electrical nerve stimulation (TENS)
6. spinal cord stimulation, electrical current to cord relieves
the pain.

From Janet Cannon:
Complex regional pain syndrome (CRPS) is also known as reflex sympathetic dystrophy (RSD) or Causalgia, a term used in the U.S. Civil War from veterans that experienced pain well after their wounds were healed. This is an uncommon nerve disorder usually happening after trauma or injury to a nerve or tissue in the affected area. Commonly seen in the extremities: hands, arms, legs or feet.

Symptoms may include dramatic changes in the colour and temperature of the skin. intense burning and sensitivity in the area, sweating and swelling (5 P's).
This chronic pain condition can occur in both male and female, but is commonly seen in women at any age.

There is no cure for CRPS. Treatment is aimed at relieving painful symptoms through a number of approaches: physical therapy, psychotherapy, sympathetic nerve blocks and medications to name a few, so the patients may resume their normal lives.

From Heather Wong:
CRPS is a chronic progressive disease characterized by "exquisite" pain, swelling, and skin changes. This disease has now been divided into two types:

l. Reflex sympathetic dystrophy (RSD) does not have demonstrative nerve damage while
2. Causalgia has demonstrated obvious nerve damage. There is no known cause that starts this syndrome. Precipitating factors have been illness, surgery and injury.

First named in the 1940s by Silas Weir Wells as RSD, but changed to CRPS in 1993 because of doubts about the pathophysiology. Possibly free radicals (bring oxidative damage to tissues when they are injured by fractures or surgery) may be the cause.
It most commonly occurs in women between the ages of 40 and 60 years, but there is increasing evidence of this syndrome in children. There is a study that shows taking Vitamin C early post-injury has decreased those susceptible to CRPS.
There are three variables of CRPS:

1. severe burning pain at injury site, muscle spasm, joint stiffness, decreased mobility of limb joint, rapid growth of hair and nails, and vasospasm
2. more intense pain, swelling, hair growth is decreased, nails are brittle, grooved and cracked, muscle atrophy, joint thickening, severe osteoporosis
3. irreversible changes to skin/bones, pain becomes unyielding, flexor tendons contract.

Treatment includes nerve blocks with immediate physio, anti­inflammatories, gabapentin meds and sympathectomy in severe cases, as a last resort. Good prognosis if treatment is started early and aggressively.