crps II

7/28/2019 crps II

1/48

7/28/2019 crps II

2/48

Identifying DataA case of Lorna B. Ulbata, 56 years old, female, single,

Filipino, Roman Catholic, presently residing at Brgy.Cancayang, Javier Leyte, admitted for the 1st time atRTRH.

7/28/2019 crps II

3/48

RightHand

Swelling

Chief

Complaint

7/28/2019 crps II

4/48

History of Present Illness Patient accidentally slide and her

right hand first touch the ground

which supported the whole body (+) swelling of the hand

(+) pain with pain scale of 7 outof 10

Went to manghihilot for 9sessions with increase of swellingnoted and was prescribed withCefalexin BID x 15 days

2months

PTA

7/28/2019 crps II

5/48

History of Present Illness

Still with swelling of the right hand &burning pain sensation radiating to theforearm and to the elbow

Consultation done at Abuyog DistrictHospital

Right hand x-ray was done

Impression: complete fracture of the

right distal radial bone with callusformation

3weeks

PTA

7/28/2019 crps II

6/48

History of Present Illness

With restrictions in the shoulder

movements (especially abduction) noted Impossible to make a fist

Consultation done to a private physician

Medications:

Alenpronale (Revanta)

Celecoxib 200mg 1 capsule Calcium+Vitamin D (Calci Pluc) 1 tab

Less relief of pain & swelling noted

1Week

PTA

7/28/2019 crps II

7/48

Past Medical History Past Hospitalization:

2009: gastric ulcer at Abuyog District Hospital

7/28/2019 crps II

8/48

Psychosocial History Patient is a self-employed

Commerce Graduate

A non-smoker Non-alcoholic beverage drinker

7/28/2019 crps II

9/48

Review of System General: No weight Loss, no body Malaise Skin: shiny, swelling right hand Head: no headache, no lightheadedness, no dizziness

Eyes: no pain, no redness Ears: no earache, no discharges Nose & Sinuses: no congestion, no nasal stuffiness Mouth & Throat: no sorethroat, no bleeding gums Neck: no pain, no rigidity

Respiratory: no dyspnea, no hemoptysis, no orthopnea Cardiovascular: no chest pain, no palpitatons GIT: good appetite, no nausea, no vomiting GUT: no hematuria, no polyuria, no dysuria, no oliguria Musculoskeletal: with muscle & joint pain at the right hand

7/28/2019 crps II

10/48

Physical Examination Patient was conscious, coherent, oriented to time,

place & person, afebrile, mesomorph, well developed,well nourished, not in cardiorespiratory distress withthe following vital signs:

BP- 140/90 mmHg

HR 112 bpm

RR 24 cpm Temperature 36.4

7/28/2019 crps II

11/48

Physical Examination Skin:

Inspection: brown complexion, with swelling & shiny

on the right right hand Palpation:warm, hyperhidrosis, with good skin turgor

Nails: pinkish nail beds with good capillary refill (

7/28/2019 crps II

12/48

Head:skull is normocephalic, black long hair equally distributed,temples not depressed, no nits, no scalp lesionno tenderness

Eyes:Eyebrows: symmetric, black hair, no lesions, no scarsEyelashes: fine black hair, ectropionEyelids: no lidlag, no ptosis, no edema, no swelling, no scarsConjunctiva: pinkish palpebral conjunctiva, no hemorrhages,no active lesions, no ulcerationsSclera: anicteric, no hemorrhage, no active lesionsCornea, Iris, Lens: with opacity, no active lesions, nolacerations or serrations

Pupils: round, asymmetrical, 2-3mm in diameter from normal

to constriction, briskly reactive to direct and consensual lightstimulation

EOM: full

7/28/2019 crps II

13/48

Ears: symmetrical, no impacted cerumen, no discharges, hearing notimpaired,no tenderness

Nose and Sinuses: pinkish mucous membrane, septum at midline, nodischarges, no congestion, no nasal flaring, no sinus tenderness

Mouth and Throat:

Lips: symmetrical, pinkish in color, no lesions, no cheilosis, and noangular deviation

Buccal mucosa: pale, moist mucous membrane, no lesions

Teeth: complete set of teeth, no false dentures

Gingiva: no swollen gums, uvula at midline

Tonsils: no enlargement, no redness, no abscess

Neck:supple, trachea at midlineBreast: symmetrical, no lesions, no discharges, no lumps, no palpable

lymph nodes, no tenderness

7/28/2019 crps II

14/48

Chest and Lungs:

Inspection: symmetrical lung expansion, no lagging, nosubscapular and intercostal retraction on respiration

Palpation: confirmed symmetrical chest expansion, unimpairedtactile fremitus, no masses, no tenderness

Percussion: resonant in all lung fields

Auscultation: no crackles, no wheezes, no pleural friction rub

Cardiovascular:

Inspection: adynamic precordium, no precordial bulging, novisible pulsation, PMI at 5th ICS left midclavicular line

Palpation: PMI noted at 5th ICS left midclavicular line, no

heaves, no thrills, no tenderness Auscultation: regular rhythm and synchronous with pulse rate,

no murmurs, no pericardial friction rub

7/28/2019 crps II

15/48

Abdomen:

Inspection: globular, no visible peristalsis, no engorged vein,no hypo/hyperpigmentation

Palpation: no tenderness, no mass, liver not enlarged,kidney not palpable

Percussion: tympanitic all over

Auscultation: normoactive bowel sounds, no arterial bruit,no venous hum, no peritoneal friction rub

7/28/2019 crps II

16/48

Extremities:Range ofMotionShoulder

PE RightShoulder

PE LeftShoulder

PE RightShoulder

PE LeftShoulder

Flexion 80 degrees 180 degrees 4/5 5/5

Extension 15 degrees 80 degrees 4/5 5/5Abduction 90 degrees 3/5 5/5

Adduction 60 degrees 90 degrees 4/5 5/5

Internal

Rotation

10 degrees 55 3/5 5/5

ExternalRotation

10 degrees 45 degrees 4/5 5/5

7/28/2019 crps II

17/48

Extremities:ROM of theElbow

Right elbow Left Elbow Right elbow Left Elbow


Extension - 10 degress 10 degrees 4/5 5/5

Supination 5 degrees 80 degrees 3/5 5/5

Pronation 70 degrees 80 degrees 4/5 5/5

7/28/2019 crps II

18/48

Extremities:ROM of theWrist

Right Wrist Left Wrist Right Wrist Left Wrist


Extension 20 degrees 70 degrees 3/5 5/5

Adduction(Radialdeviation )


Abduction(UlnarDeviation)


7/28/2019 crps II

19/48

Extremities:ROM of the fingers &Thumb

Right Left

First interphalangealflexion

10 degrees 80 degrees

Second, third, and fourthinterphalangeal flexion

10 degrees 100 degrees

7/28/2019 crps II

20/48

SensorySensationTesting

Light touch Pinprick

C5 Lateral side of theantecubital fossa

+++ +++

C6 Thumb +++ +++

C7 Middle Finger +++ +++

C8 Little finger +++ +++

T1 Medial side of the

antecubital fossa

+++ +++

7/28/2019 crps II

21/48

ReflexesBiceps Triceps Brachialis Knee AnkleRight 1+ 1+ 1+ 2+ 2+

Left 2+ 2+ 2+ 2+ 2+

7/28/2019 crps II

22/48

Neurologic Exam:

MENTAL STATUS EXAM: alert, coherent and oriented to person, place, andtime, no mental changes and confusion noted.

CRANIAL NERVES:

CN I: no anosmia

CN II & III: pupils 2-3 mm in diameter, symmetrical, equally reactive to

direct and consensual light stimulation CN III, IV, VI: able to move eyes upward, downward, medially and laterally

CN V: intact sensory function to pain and touch, with intact corneal reflex

CN VII: able to smile, able to frown

CN VIII: responsive to verbal stimuli

CN IX and X: with intact gag reflex, able to swallow

CN XI: able to turn head to both sides against resistance, able to shrugshoulder

CN XII: able to protrude tongue, no deviation to L/R

7/28/2019 crps II

23/48

Course in the WardsAdmission

1stst HOSPITAL DAY

Motor: increase of the ROM of the shoulder Less swelling

2nd HOSPITAL DAY

Motor: increase of the ROM of the shoulder

No swelling

7/28/2019 crps II

24/48

Diagnostics Procedure

Results

Hemoglobin 150Hematocrit 0.42

WBC 7.85

Neutrophils 0.72

Lymphocytes 0.27

Monocytes 0.01

7/28/2019 crps II

25/48

7/28/2019 crps II

26/48

7/28/2019 crps II

27/48

Salient Features1. 56 years old2. Female3. Single4. Swelling of the right hand5. Injury of the right hand for about 2 months ago6. Continuous Burning Pain radiating to the forearm & elbow7. Decreased ROM of the right shoulder, elbow, wrist, fingers &

thumb Restriction of right shoulder movement With restrictions in the shoulder movements (especially

abduction) noted Impossible to make a fist

8. Hyperesthesia, allodynia, hyperhidrosis

7/28/2019 crps II

28/48

7/28/2019 crps II

29/48

NERVE ENTRAPMENT/

COMPRESSION SYNDROMESRule In Rule Out

1. Swelling of the right hand

2. Injury of the right hand for about2 months ago

3. Continuous Burning Pain

1. Continuous Burning Pain

radiating to the forearm & elbow2. Decreased ROM of the right

shoulder, elbow, wrist, fingers &thumb Restriction of right shoulder

movement

With restrictions in theshoulder movements(especially abduction) noted

Impossible to make a fist

7/28/2019 crps II

30/48

FibromyalagiaRule In Rule out56 years oldFemale regional areas of pain

11/18 tender pointRelated to sleep, problems anxiety ordepression

7/28/2019 crps II

31/48

Posttraumatic neuralgiaRule In Rule Out1. Injury of the right hand for about

2 months ago2. Decreased ROM of the right

shoulder, elbow, wrist, fingers &thumb

3. Continuous Burning Pain4. Weakness of the right hand

1. Swelling of the right hand2. progressive spread of symptoms.3. obtain relief with sympatholytic

procedures

7/28/2019 crps II

32/48

COMPLEX REGIONAL PAIN

SYNDROME (CRPS)RULE IN RULE OUT

1. 56 years old2. Female3. Single

4. Swelling of the right hand5. Injury of the right hand for about 2 months ago6. Continuous Burning Pain radiating to the forearm & elbow7. Decreased ROM of the right shoulder, elbow, wrist, fingers

& thumb Restriction of right shoulder movement With restrictions in the shoulder movements

(especially abduction) noted Impossible to make a fist

8. Hyperesthesia, allodynia, hyperhidrosis

7/28/2019 crps II

33/48

ANATOMY & PHYSIOLOGY

7/28/2019 crps II

34/48

7/28/2019 crps II

35/48

Brachial Plexus

7/28/2019 crps II

36/48

CRPS is a neuropathic pain syndrome characterized by

autonomic dysfunction and severe pain that may leadto crippling contractures of the limbs.

A variety of painful conditions following injury whichappears regionally having a distal predominance ofabnormal findings exceeding in both magnitude andduration the expected clinical course of the incitingevent, often resulting in significant impairment ofmotor function and showing variable progression overtime

7/28/2019 crps II

37/48

CRPS COMPLEX varied and dynamic clinical presentation

REGIONAL non-dermatomal distribution of thesymptoms

PAIN out of proportion to the inciting events

SYNDROME constellation of symptoms and signs

7/28/2019 crps II

38/48

International Association for the

Study of Pain (IASP) Nomenclature CRPS I = reflex sympathetic dystrophy

CRPS II = causalgia

A.K.A = algodystrophy, shoulder-hand syndrome,Sudeck's atrophy, transient osteoporosis and acute

atrophy of bone

7/28/2019 crps II

39/48

CRPS Female to male ratio: 3:1

Any age, but middle age predominates (median 42years old)

Onset 9-85 years old

CRPS occurs in about 1-2% of patient who have hadfractures and in approximately 2-5 % of patients after

peripheral nerve injuries

7/28/2019 crps II

40/48

Clinical Manifestation1. Pain

Continuous , constant, burning, aching, throbbing

Disproportionate to the injury

Asymmetrical and not in distributuion of a peripheralnerve, worst in distal

2. Autonomic abnormalities

Vascular: hot swollen erythematous/cold, blached &mottled

Sudomotor: Hyperhydrosis

7/28/2019 crps II

41/48

Clinical Manifestation1. Motor

Diffuse weakness of the extremity

2. Trophic changes

Nail growth

Loss of function: muscle, joints & tendon

Hair changes (coarse/loss of hair)

Skin-thin and glossy, loss of elasticity osteoporosis

7/28/2019 crps II

42/48

CRPS I1. The presence of an initiating noxious event or acause of immobilization

2. Continuing pain, allodynia or hyperalgesia with

which the pain is disproportionate to the incitingevent.

3. Evidence of some time of edema, changes in skinblood f low or abnormal sudomotor activity in the

region of pain4. The diagnosis is excluded by the existence of

conditions that would otherwise account for thedegree of pain & dysfunction

7/28/2019 crps II

43/48

CRPS II (Causalgia) Criteria1. The presence of continuous pain, allodynia or

hyperalgesia after a nerve injury, not necessarilylimited to the distribution of the injured nerve

2. Evidence of some time of edema, changes in skinblood f low or abnormal sudomotor activity in theregion of pain

3. The diagnosis is excluded by the existence ofconditions that would otherwise account for thedegree of pain & dysfunction

7/28/2019 crps II

44/48

PathophysiologyUnknown

3 main hypotheses

Facilitated neurogenic inflammation

Autonomic dysfunction

Neuroplastic changes within the CNS

7/28/2019 crps II

45/48

Treatment Goals Relief of pain

Return of function

Prevent or slow the progression

7/28/2019 crps II

46/48

Treatment1. Physical Therapy2. Pain

Eterocoxib 120 mg 1 tab OD

NSAIDs

3. Steroids

4. Gabapentin & Pregabalin

5. Calcitonin

7/28/2019 crps II

47/48

Sympathetic Blockade Lumbar sympathetic block

Stellate ganglion block

IV regional anesthesia block

7/28/2019 crps II

48/48

Documents

crps II