Complex regional pain syndrome

Abstract

CLINICAL PROBLEM A 45-year-old female dentist fell on a slippery floor at work and immediately felt pain in her right wrist. Her physician diagnosed a sprained wrist without bony fracture or rupture of the ligaments. The physician wrapped a bandage around the wrist, and anti-inflammatory analgesics were prescribed to alleviate the pain. Rest, ice application, and elevation of the hand higher than the elbowwere recommended, and after 3 or 4 days, everything seemed fine. However, in the following week, she felt a burning pain in her hand and forearm that became steadily worse. She also noted swelling over the dorsum of her right hand. In subsequent months, the dentist was having difficulties in performing her job owing to muscle weakness and severe pain with movement of her arm. She also noticed sweating in the region of the painful area, as well as increased growth of her fingernails and of the hair on the dorsum of her right hand. Three months after her injury, the dentist visited a university pain clinic. On physical examination, her orthopedist observed erythematous, edematous, and shiny skin on the swollen distal part of her forearm and the dorsal side of her hand. Passive and active range of motion of her wrist was restricted. Physical systemic examination and blood test results revealed no abnormality. On neurologic examination, hyperalgesia and allodynia were noted in her right forearm, wrist, and hand. Results of nerve conduction studies were normal. Grip strength was 7 kilograms and 24 kg in the right and left wrists, respectively. Radiographs showed decalcification in her right carpal bones. Thermography revealed a temperature 1.0 C higher than on the unaffected side.