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Abstract
Chronic pain is often associated with sensorimotor dysfunction but little is known about the early impact of limb fracture on sensory and motor performance. This exploratory study sought to assess these changes in patients with recent wrist and ankle fractures. A secondary aim was to determine the incidence of Complex Regional Pain Syndrome (CRPS) and its clinical features. Fifty-three patients at a UK fracture centre underwent Quantitative Sensory Testing (QST), Motor Imagery (MI) and Body Perception Disturbance (BPD) assessments ≤5weeks post-fracture (Time 1). Subjective evaluation of recovery and clinical examination for CRPS was conducted 5weeks later (Time 2, 50 patients). Patient-reported outcomes of pain, psychological distress and limb function were collected at Times 1 and 2, and 6months after T1 (Time 3, 36 patients, postal questionnaire). Quantitative sensory testing at Time 1 demonstrated cold and pressure-pain hyperalgesia in the fractured limb compared to the non-fractured side (p<0.05). Imagined movements were reported as significantly more difficult to perform on the fractured side (p<0.001). There was evidence of BPD in the fractured limb, similar to that found in CRPS. The incidence of CRPS was 9.4%; however, individual signs and symptoms of the condition were commonly present (70% reported ≥ one symptom). Only 33% of patients reported to being 'back to normal' 6months after fracture with 34% reporting ongoing pain. Limb fracture is associated with changes in pain perceptions, motor planning, and disruption to body perception. Signs and symptoms of CRPS, ongoing pain and delayed recovery post-fracture are common. WHAT DOES THIS STUDY ADD?: In the immediate post-fracture period: Body perception disturbance is reported in the fractured limb. Imagined movements of the fractured limb are less vivid and associated with pain This study contributes to the incidence literature on CRPS.
Highlights
Limb fracture is a relatively common injury with approximately 55,000 wrist and60,000 ankle fractures per annum in the UK (Court-Brown et al, 1998; O'Neill et al, 2001; Van Staa et al, 2001)
The purpose of this study was to explore the impact of limb fracture on sensory and motor systems in order to identify the frequency of observed changes in these systems in an early post-fracture cohort, and to examine their relationship with patientperceived recovery
Patient demographics and clinical characteristics Fifty-three patients were recruited with a mean age of 54 years (S.D. = 18 years); 36 (68%) were female; 36/17 (68/32%) had fractured a wrist/ankle with 13/40 fracturing their dominant side (24.5/75.5%); and the mean time since fracture at Time 1 (T1) was 31 days (S.D. = 12 days)
Summary
60,000 ankle fractures per annum in the UK (Court-Brown et al, 1998; O'Neill et al, 2001; Van Staa et al, 2001) It is a traumatic event often associated with pain and systemic disability beyond the local effect of the injury. CRPS is a persistent pain condition, of unknown aetiology, with pain disproportionate to the inciting event, usually confined to the injured limb It is characterised by extreme pain and sensory, motor and autonomic disturbances (Harden et al, 2010). Motor impairment is characteristic of CRPS, reflecting dysfunction in motor planning processes (Maihöfner et al, 2007; Schilder et al, 2012; Bank et al, 2013) This is considered, in part, to be mediated by distortion of mental image of the affected limb (Moseley, 2005; Lewis et al, 2010), which has been reported to occur early in onset (Lewis et al, 2007). 33% of patients reported to being “back to normal” 6 months after fracture with 34% reporting on-going pain
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