Complex regional pain syndrome

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By Steven H Horowitz MD

Fortunately, complex regional pain syndrome rarely develops without a known predisposing event such as trauma or immobilization. After a fracture, cast tightness should be carefully assessed, and the limb recast if pressure within the cast becomes excessive due to swelling. The cast should be removed and the limb mobilized as soon as it is safe from an orthopedic standpoint. If range of motion appears less than expected, physical therapy should aggressively increase range of motion. Before removal of the cast, motion should be encouraged across uninvolved joints of the same limb. There is level II evidence that the use of vitamin C (500 to 1000 mg for 50 days) from the date of injury reduces the development of CRPS I in patients with wrist fractures (Perez et al 2010). In patients with a previous history of CRPS anywhere in the body, the risk of new CRPS is increased; therefore, surgery should be restricted to operations with unequivocal indications and no available alternative conservative treatment and postponed until CRPS I signs are minimal, if possible (Perez et al 2010). There is level III evidence that perioperative administration of salmon calcitonin may help prevent development of CRPS I postoperatively (Perez et al 2010).

CRPS has been described in patients with hemiparesis due to stroke, especially in the upper extremities, due to biomechanical factors and microtrauma (Chae 2010). Care should be taken post-stroke not to injure any joint or joint capsule, especially the shoulder. All caregivers should be informed of the loss of sensation on the affected side and the consequent absence of forewarning by the patient with passive movement.