The February 2024 Trauma Roundup. 360. looks at: Posterior malleolus fractures: what about medium-sized fragments?; Acute or delayed total hip arthroplasty after acetabular fracture fixation?; Intrawound antibiotics reduce the risk of deep infections in fracture fixation; Does the VANCO trial represent real world patients?; Can a restrictive transfusion protocol be effective beyond initial resuscitation?; What risk factors result in avascular necrosis of the talus?; Pre-existing anxiety and mood disorders have a role to play in complex regional pain syndrome; Three- and four-part proximal humeral fractures at ten years

Complex regional pain syndrome type 1 (CRPS-I) is a devastating complication that can occur after limb extremity injuries. The effectiveness of vitamin C in preventing CRPS-I incidence is debatable. Therefore, we conducted a systematic review and meta-analysis to assess the role of vitamin C in CRPS-I prevention and its effect on pain score, functional outcomes and complications rate after wrist, ankle, and foot fractures. We searched Medline, Embase, the Cochrane Library, . Clinicaltrial.gov. , and Google Scholar from infinity to May 2021 for relevant studies comparing the incidence of CRPS-I with administration of perioperative vitamin C versus placebo after wrist, ankle, and foot fractures. Continuous data such as functional outcomes and pain scores were pooled as mean differences (MD), whist dichotomous variables such as the incidence of CRPS-I and complications were pooled as odds ratios (OR), with 95% confidence interval (CI). Data analyses was done using R software (meta package, version 4.9-0) for Windows. Eight studies, including two quasi-experimental studies, were included. The timeframe for vitamin C administration ranged from 42 to 50 days post-injury and/or surgical fixation and the dosage was either 500 mg or 1000 mg. The results showed that vitamin C was associated with a lower rate of CRPS-I relative to a placebo (OR 0.33, 95% CI [0.17, 0.63]). No significant difference was found between vitamin C and placebo in terms of complications (OR 1.90, 95% CI [0.99, 3.65]), functional outcomes (MD 6.37, 95% CI [-1.40, 14.15]), and pain scores (MD -0.14, 95% CI [-1.07, 0.79]). The findings demonstrate that when compared to placebo, at least 42 days of vitamin C prophylaxis is associated with prevention of CRPS-I following wrist, ankle, and foot fractures, irrespective of vitamin C dosage or fracture type. No significant differences were found with secondary outcomes

We studied prospectively the regional inflammatory response to a unilateral distal radial fracture in 114 patients at eight to nine weeks after injury and again at one year. Our aim was to identify patients at risk for a delayed recovery and particularly those likely to develop complex regional pain syndrome. In order to quantify clinically the inflammatory response, a regional inflammatory score was developed. In addition, blood samples were collected from the antecubital veins of both arms for comparative biochemical and blood-gas analysis. The severity of the inflammatory response was related to the type of treatment (Kruskal-Wallis test, p = 0.002). A highly significantly-positive correlation was found between the regional inflammatory score and the length of time to full recovery (r. 2. = 0.92, p = 0.01, linear regession). A regional inflammatory score of 5 points with a sensitivity of 100% but a specificity of only 16% also identified patients at risk of complex regional pain syndrome. None of the biochemical parameters studied correlated with regional inflammatory score or predicted the development of complex regional pain syndrome. Our study suggests that patients with a distal radial fracture and a regional inflammatory score of 5 points or more at eight to nine weeks after injury should be considered for specific anti-inflammatory treatment

Complex regional pain syndrome is characterised by an exaggerated response to injury in a limb with intense prolonged pain, vasomotor disturbance, delayed functional recovery and trophic changes. This review describes the current knowledge of the condition and outlines the methods of treatment available with particular emphasis on the knee

Aims. Amputation in intractable cases of complex regional pain syndrome (CRPS) remains controversial. . The likelihood of recurrent Complex Regional Pain Syndrome (CRPS), residual and phantom limb pain and persistent disability after amputation is poorly described in the literature. The aims of this study were to compare pain, function, depression and quality of life between patients with intractable CRPS who underwent amputation and those in whom amputation was considered but not performed. Patients and Methods. There were 19 patients in each group, with comparable demographic details. The amputated group included 14 men and five women with a mean age of 31 years (. sd. 12) at the time of CRPS diagnosis. The non-amputated group consisted of 12 men and seven women and their mean age of 36.8 years (. sd. 8) at CRPS diagnosis. The mean time from CRPS diagnosis to (first) amputation was 5.2 years (. sd 4. 3) and the mean time from amputation to data collection was 6.6 years (. sd. 5.8). . All participants completed the following questionnaires: Short-Form (SF) 36, Short Form McGill Pain questionnaire (SF-MPQ), Pain Disability Index (PDI), the Beck Depression Inventory (BDI) and a clinical demographic questionnaire. . Results. The amputation group showed consistently better results compared to the non-amputation group in the following parameters: median pain intensity (VAS): 80 (inter-quartile range (IQR) 13 to 92) vs 91 (IQR 85 to 100); p = 0.007; median SF-MPQ score 28 (IQR 9 to 35) vs 35 (IQR 31 to 38), p = 0.025; median PDI: 42 (IQR 11 to 64) vs 58 (IQR 50 to 62), p = 0.031; median BDI: 19 (IQR 5 to 28) vs 27 (IQR 21 to 32), p = 0.061 (borderline significant) and in six of the eight SF-36 domains. . Take home message: Amputation should be considered as a form of treatment for patients with intractable CRPS. Cite this article: Bone Joint J 2016;98-B:548–54

Thirty-three patients with reflex sympathetic dystrophy were studied prospectively to ascertain the pressure-pain threshold of affected and unaffected limbs. The affected side had a lower threshold which was found to be statistically significant. In all 18 patients with upper limb involvement, the pain threshold was reduced on the affected side, but this applied to only 11 of the 15 with leg involvement. This difference may be because patients with lower limb symptoms had been referred later in the course of the syndrome. We showed by repeated tests that after an average of 49 days there was a slow return to normality. The estimation of pressure-pain thresholds may help in the earlier diagnosis of reflex sympathetic dystrophy

Reflex sympathetic dystrophy is a syndrome characterised by pain and hyperaesthesia associated with swelling, vasomotor instability and dystrophic changes of the skin. It is rare in children, can occur without any previous history of significant trauma and may be recurrent and migratory. We reported 13 new cases of RSD in children and emphasised the role of a multidisciplinary team approach in management. A review of the literature was included. 13 children (3 boys and 10 girls) with reflex sympathetic dystrophy were presented. They were aged between 8 and 17 years. Mean age at onset was 13 years 4 months. All of them had RSD involving the lower limbs. Thermography was performed in 10 cases. The average time to correct diagnosis was 4 months. Five ankles, 4 knees and 5 hips were involved (14 joints in 13 cases). Psychological assessments revealed abnormalities in all cases. Pain (visual analogue score) and function were assessed before and after treatment. The most common therapy in children is progressive mobilisation supported by analgesic drugs, psychological and physical therapy. We individualised the therapy for each child. A team-care approach with the physiotherapist, psychologist and pain-care team co-ordinated by the Orthopaedic Consultant was the essence of our management. All children received physical therapy including a wide variety of non-standarised approaches involving analgesics and hydrotherapy. 5 patients received guanithidine blocks. Individual therapy was monitored with set achievable goals and weekly assessment of progression of mobility and joint motion. Time from the first RSD episode to resolution averaged 6 months in our series [it was mean 10 weeks in the non-adolescent cases (8 cases) and 7 months in the adolescent one (5 cases)]. The pain and function scores improved remarkably in all patients. RSD in children is not a widely recognised condition. There is often a delay in diagnosis in view of the rarity of the condition as well as the fact that specific diagnostic modalities are not readily available in all centres. Psychological factors should not be underestimated. Early diagnosis with an aggressive, multidisciplinary, monitored, ‘goal-oriented’ team approach should be the basis of management in these cases

Aim: There are more than 50 methods for the treatment of Reflex Sympathetic Dystrophy Our aim is to test how effective is the treatment of patients with Reflex Sympathetic Dystrophy with guanethidine. Method: 15 patients (F=12, M=3, Mean age 59.9) were seen in the chronic pain clinic with Reflex Sympathetic Dystrophy. 13 patients had sustained a Colles fracture and 11 of them had a closed reduction and application of POP and 2 had an external fixation. 1 had an operation for release of median nerve and 1 amputation of 3 fingers due to trauma. There were first seen in the Pain Clinic 12–16 weeks after the initial injury. Main symptoms were pain and stiffness. On examination all of them had oedema of the hand, stiffness and discoloration. Allodynia was present in 8. Patsy osteoporosis was evident on the x-rays. Palmar elytritis with atrophy in 6. The treatment was intravenous sympathetic block with 20 mg guanethidine plus 2ml 2% lignocaine and N/Saline up to 20 ml. The second block was repeated after 3 days and the following depending on the response to pain. Physiotherapy session followed each block. Results: 2 patients needed 5 blocks, 7 patients 4 blocks, 5 patients 3 blocks and 1 patient 2 blocks. In the end there was complete regression of the pain, oedema and restoration of the movement. Conclusion: The sympathetic block with I.V. administration of guanethidine in combination with physiotherapy seems to be a safe and simple treatment of choice, well tolerated and with good results

Introduction Reflex sympathetic dystrophy (RSD) as a complication of total knee arthroplasty (TKR) is rarely mentioned. The literature has been limited to 58 cases of RSD in TKR, a prevalence of 0.8% of all TKR done. No previous reports give a clear understanding as what to expect in the long term after the diagnosis of RSD post TKR has been made nor do they report the struggle that patients undergo to achieve their result. Methods We report on 11 cases of RSD diagnosed post TKR, operated on by one of us from 1991 to 2001. All patients met diagnostic criteria for Complex Regional Pain Syndrome, Type 1. Specifically they exhibited slow post-operative recovery and delayed return of normal function. Flexion was limited and cutaneous hypersensitivity was present along with temperature changes in the limb. These patients were evaluated using general and disease specific outcome tools previously validated in the literature, the SF-36 and WOMAC scores. In addition they were evaluated clinically at minimum two years following resolution of symptoms. Results We found that once appropriate treatment had been instituted, which in our case was manipulation under anaesthetic in the painfree phase of CRPS-I, the majority of our patients reported higher scores on the bodily pain section of SF-36 however these were still lower than age matched controls of pre-operative osteoarthritic patients as determined by WOMAC scores. In general, though patients had poorer SF-36 and WOMAC scores than primary uncomplicated TKR, they did significantly better than primary osteoarthritics without surgery. Conclusions This would suggest that when appropriately managed, RSD after TKR does not hold the dire prognostic consequences as previously thought

Reflex sympathetic dystrophy of the knee has been studied in a series of 19 patients. Those diagnosed and treated early (at less than six months) did much better than those diagnosed and treated late. Nevertheless, when these patients were followed up at an average of 3.4 years from onset, not one was completely normal to objective tests with the Cybex II dynameter, an indication of the adverse prognosis with current methods of treatment

We have reviewed 28 patients with reflex sympathetic dystrophy (RSD) who had 34 amputations in 31 limbs. The amputations had been performed for untenable pain (5), recurrent infection (14) or to improve residual function (15). Only two patients were relieved of pain by amputation, and this could not be predicted. Ten of 14 patients were cured of infection and 9 of 15 patients had improvement of residual function. In 28 of the amputations, RSD recurred in the stump, especially after amputation at a level which was not free from symptoms. Because of recurrence of RSD in the stump or severe hyperpathia only two patients wear a prosthesis. Despite this 24 patients were satisfied with the results

Complex regional pain syndrome (CRPS) is a devastating complication that is very difficult to treat. Whilst uncommon, the condition is frequently encountered by extremity surgeons. The author has considerable experience of dealing with CRPS and, with three clinical cases, will describe how the condition is diagnosed and treated. The very real clinical situation of timing for surgery in patients who have suffered from CRPS is also to be discussed

Thirty-six patients with reflex sympathetic dystrophy primarily affecting the knee were reviewed. Injuries or operation about the patellofemoral joint triggered its onset in 64% of patients. Co-existent mechanical derangement of the knee was present in 64% of patients. Those patients who underwent sympathetic blockade or sympathectomy within one year of onset of symptoms had significantly better pain and function scores than those in whom intervention was later. Early diagnosis remains the key to successful management. Surgery for co-existent mechanical derangement in the affected knee should not be performed until the syndrome is controlled

Diagnosis of complex regional pain syndrome (CRPS) can be challenging. We explore the role of fracture clinic in diagnosis and management with a closed-loop audit of new guidelines. We retrospectively reviewed patients with CRPS over 3.5 years. We determined the delay from injury to commencement of treatment and monitored symptoms. New guidelines were introduced to fracture clinic in January 2013. The Budapest Criteria aids diagnosis. GAD-7 and PHQ-9 patient questionnaires grade symptoms. Orthopaedic surgeons prescribe nortriptylline or pregabalin, refer to physiotherapy and review patients after six weeks. We re-audited prospectively after implementing these guidelines. The first audit cycle found 11 patients in 3.5 years. The mean delay to anti-neuropathic medication from injury was 4.7 months. Two patients required psychotherapy, one intravenous pamidronate, three inpatient physiotherapy under nerve blocks and two spinal cord stimulators. After implementing guidelines, there were 14 patients with CRPS in 9 months. All but two patients received anti-neuropathic medication on the day of diagnosis. All patients treated appropriately improved markedly within 4–12 weeks. No patients required escalation of treatment. Our guidelines increased pick-up rates of CRPS, diagnoses were made earlier and treatment started sooner. Physiotherapy modalities remained varied, however, early anti-neuropathic treatment led to a rapid improvement in all cases

Complex Regional Pain Syndrome (CRPS) is regarded as an uncommon clinical complication to orthopaedic surgery. Few have looked into its prevalence in foot and ankle surgery. This is a retrospective cohort study of all patients undergoing foot and ankle surgery, operated on by the foot and ankle team in our department in 2009. The objectives of this study was to determine the prevalence CRPS in these patients post-operatively and to examine the associated factors. 17 patients from 390 (4.4%) were identified as meeting the IASP (International Association for the Study of Pain) criteria for the diagnosis of CRPS. Of these, the majority were female (n = 14, 82.4%) and the average age was 47.2 (SD 9.7). All were elective patients. The majority involved operating on the forefoot (n = 9, 52.9%), followed by the hindfoot and ankle (3 cases each, 17.6%). Most of these patients had new onset CRPS (n = 12, 70.6%), with no previous history of the condition. 3 patients (17.6%) had documented nerve damage and therefore suffered from CRPS Type 2. Blood results were available for 14 (82.4%) patients at a minimum of 3 months post-operatively, and none had elevated inflammatory markers. 5 of the patients (29.4%) were smokers and 8 (47.1%) had a pre-existing diagnosis of anxiety or depression. At present, based on our findings, we recommend that middle-aged women, with a history of anxiety or depression, undergoing elective foot surgery be specifically counselled on the risk of developing CRPS at consenting. We recommend similar studies to be undertaken in other West of Scotland orthopaedic units

Introduction: Although well-recognized in adults, RSD is rarely diagnosed in children. Management is still controversial and includes, mobilization and physical therapy, spinal cord stimulation, transcutaneous electrical nerve stimulation, steroids, tricyclic antidepressants, anticonvulsants, non-steroidal anti-inflammatory drugs, injections of calcitonin, vasodilators and calcium channel blocker or alpha-sympathetic blocker. In this study, we describe the treatment of RSD in children using Iloprost, a pros-tacyclin analog that mimics sympathicolysis. We report our treatment regime, the clinical course, complications and the outcome in our first seven patients. Patients and Methods: Seven female patients with a mean age of 9 years (6 to 11 years) suffering from reflex sympathetic dystrophy (RSD) stage II were included in this prospective study. Inclusion criteria were RSD stage II – III, an age between 4 to 12 years, no previous operative procedures and duration of symptoms for a minimum of 6 months. Diagnosis of RSD was based on the presence of neuropathic pain, such as burning, dysaesthesia, paresthesia, and hypalgesia to cold, and physical signs of autonomic dysfunction such as skin cyanosis, mottling, hyperhidrosis, edema and coldness of the extremity. Treatment regime consisted of two infusions of Iloprost (IlomedinÒ, Schering AG, Germany) administered over 6 hours on two consecutive days. Additionally, all patients underwent physiotherapy as part of their inpatient treatment and were offered psychological counselling. Results: One day after the last infusion, all seven patients were free of pain and full weight-bearing was possible. The side-effects of Iloprost were a headache in all patients and vomiting in two patients. Two patients relapsed, one 3 months and one 5 months after primary treatment. These two patients received a second series of infusions and were again free of pain within two days. During a mean follow-up period of 30 months all patients remained asymptomatic. Conclusion: These preliminary results indicate that the treatment of RSD with Iloprost in combination with psychological counselling is a safe and effective treatment regime. Infusion therapy is a non-frightening procedure which may be an important factor considering the possible psychogenic etiology of RSD in children. Additional psychological counselling helps patients and their parents to develop coping strategies which may help to avoid relapses

Complex regional pain syndrome (type 1) (CRPS) is a chronically painful and disabling condition commonly encountered following trauma and surgery to an extremity. The condition comprises of a combination of pain, swelling, sensory impairment, joint stiffness, trophic changes, motor abnormalities and vasomotor instability. Post-traumatic CRPS is a significant clinical problem presenting to the orthopaedic surgeon and pain specialist. A clear understanding of the condition has been hampered by a lack of uniformity of diagnostic criteria (. Van de Beek W-JT, et al . Neurology. 2002. ;. 58. :. 522. –526. ). Pain therapists use the International Association of Pain (IASP) criteria (. Bruehl S et al . Pain. 1999. ;. 81. :. 147. –154. ) and orthopaedic surgeons the Atkins criteria (. J Bone Joint Surg. 1990. ;. 72B. :. 105. –110. ). Breuhl’s criteria use a combination of symptoms and signs from 4 distinct groups (hypersensitivity; vasomotor; swelling and sudomotor; motor and trophic). Atkins’ criteria require the finding of vasomotor instability symptoms, abnormal finger dolorimetry and abnormal finger range of movements. We have compared these different criteria on a series of 262 patients with distal radial fracture. The incidence of CRPS was similar using either criteria (Bruehl 20.61% vs. Atkins 22.52%). Using the Bruehl criteria as a gold standard, there was strong diagnostic agreement (Kappa = 0.79, sensitivity = 0.87, specificity = 0.94). The main difference between the two methods was in pain assessment. 16 patients had vasomotor instability, swelling and motor changes but 12 did not complain of hypersensitivity although the dolorimetry ratio was lowered. These cases have CRPS by the Atkins criteria but not the Bruehl. In contrast 4 of these cases had normal finger dolorimetry but abnormal forearm hypersensitivity and therefore had CRPS by the Bruehl criteria and not the Atkins. These finding show that the Bruehl and Atkins criteria are basically concordant. The differences reflect only minor variations in the assessment of pain. Agreement between researchers in the orthopaedic and pain therapy communities will allow improved understanding of the pathophysiology, possible prevention and future methods of managing CRPS

Purpose of the study: The pathophysiology of reflex dystrophy or type I complex regional pain syndrome remains poorly understood, but the cost is considerable in terms of public health expenditures both for programmed and emergency orthopedic surgery. We present a historical cohort assessed to evaluate the usefulness of vitamin C for the prevention of reflex dystrophy in programmed foot and ankle surgery. Material and methods: The study included two groups of patients treated in two successive periods: July 2002 to June 2003 and July 2003 to June 2004. All patients underwent foot and ankle surgery performed by the same senior surgeon. Diabetic feet were excluded. The first group (185 feet, 177 patients) was not given any particular preventive treatment. The second group (235 feet, 215 patients) was given one gram vitamin C for 45 days. The diagnosis of reflex dystrophy was retained on the basis of clinical and radiological arguments noted at follow-up visits with the operator. Several factors were studied: gender, age, type of disease condition, history of reflex dystrophy, psychological context, duration of tourniquet, cast immobilization. Results: Reflex dystrophy occurred in 18 feet in group. 1 (9.6%) and in 4 (1.7%) in group 2. The difference was significant. Presence of a history of dystrophy was significantly associated with development of dystrophy (RR=10.4). A psychological context appeared to increase the risk of dystrophy (RR 2.6) but did not reach significance. There was no statistical relationship with age, gender, duration of tourniquet, type of disease condition, or surgical procedure performed. Discussion: Vitamin C has been found to be effective in the prevention of reflex dystrophy after wrist fractures. Data in the literature is scarce on dystrophy of the foot and ankle. Our study provided objective evidence of the usefulness of vitamin C for the prevention of reflex dystrophy in foot and ankle surgery patients, a complication frequently observed in our control group (9.6%). The psychological context and history of dystrophy increase the risk of dystrophy. Conclusion: Vitamin C is associated with a lower risk of reflex dystrophy in the postoperative period after foot and ankle surgery. We advocate preventive treatment with vitamin C

A total of 57 patients, aged between 23 and 86 years, with complex regional pain syndrome (CRPS) type 1 nine weeks after an isolated closed fracture of the distal radius, was randomised to receive either serial intravenous regional blockade (IVRB) with 15 mg of guanethidine in 30 ml of 0.5% prilocaine or serial IVRB with 30 ml of normal saline at weekly intervals until the tenderness in their fingers had resolved or they had received a maximum of four IVRBs. The analgesic efficacy was assessed at 24 hours, 48 hours and one week after each procedure by the dolorimetry ratio and verbal pain scores, and at intervals up to six months after the fracture. There was no significant difference in the number of IVRBs administered or in finger tenderness, stiffness or grip strength between the two groups. The guanethidine group experienced more pain in the affected hand (p = 0.025) and at six months had more vasomotor instability (p < 0.0001) compared with the control group. IVRB using guanethidine offers no significant analgesic advantage over a normal saline placebo block in the treatment of early CRPS type 1 of the hand after fracture of the distal radius. It does not improve the outcome of this condition and may delay the resolution of vasomotor instability when compared with the placebo