Reflex Sympathetic Dystrophy After Distal Radius Fracture
A 47-year-old woman had a distal radius fracture treated with closed reduction and casting 8 weeks ago. The cast was removed 2 weeks ago. She now reports burning pain in the hand and wrist, 7/10, worse with light touch and cold, with swelling and color changes. She cannot tolerate having the hand examined without wincing. Exam: diffuse allodynia over the dorsum of the hand, edema, mottled skin, and temperature asymmetry compared with the left. Wrist flexion is 20° (expected 60°), extension 15°. She is tearful and says, "Nobody believes how much this hurts."
1. What is your diagnosis, and what criteria support it?
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Complex regional pain syndrome (CRPS) type I, following a fracture without nerve injury. This meets the Budapest criteria:
- Sensory: burning pain and allodynia disproportionate to the inciting event.
- Vasomotor: temperature and color asymmetry.
- Sudomotor/edema: swelling.
- Motor/trophic: reduced range of motion and weakness.
- Symptoms are not better explained by another diagnosis.
Key reasoning: the distribution is regional and the findings span multiple categories, which distinguishes CRPS from simple post-fracture stiffness or a single nerve entrapment. The emotional distress is real and should be validated, not dismissed.
2. What is your treatment plan, and how do you address her fear and the psychosocial dimension?
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Multimodal, early, and function-focused:
- Rehabilitation: gentle graded desensitization (textures, contrast baths), edema control, and progressive range-of-motion and functional tasks. Avoid forcing painful motion; pace activity.
- Medication: consider gabapentinoids or a trial of a tricyclic for neuropathic pain; topical lidocaine for allodynia. Coordinate with pain management.
- Interventional: sympathetic block or other procedures may be considered if symptoms persist; refer early rather than late.
- Psychological: validate her pain, explain CRPS clearly, and involve behavioral health for coping and pacing. Screen for depression and anxiety.
- Education: reassure that CRPS is treatable and that early, consistent participation improves outcomes.
Avoid labeling her as "noncompliant" - pain-avoidance is physiologic here.
3. How do you set functional goals and measure progress over the next 3 months?
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Set SMART, function-based goals, not just range-of-motion targets:
- Within 4 weeks: tolerate light touch on the hand for daily tasks, reduce pain flare duration.
- Within 8–12 weeks: improve wrist range of motion toward functional range, perform grooming and dressing with the affected hand.
- Track with validated measures: pain numeric rating scale, range of motion, grip strength, and a function measure such as the QuickDASH.
- Document flare management (pacing, rest, desensitization) and a clear escalation pathway.
Reassess at each visit; if pain and dysfunction are not improving, revisit the diagnosis and escalate to a multidisciplinary pain program.