P. Doury Y Dirheimer S. Pattin

Algo dys trophy Diagnosis and Therapy of a Frequent Disease of the Locomotor Apparatus

With a Foreword by IVilliaumey

Translated by M.-Th.Wackenheim

With 46 Figures

Springer-Verlag Berlin Heidelberg New York 1981

Professeur PAUL DOURY Service de Rhumatologie des Armees, H6pital Begin F-94160 Saint-Mande

Dr. YVES DIRHElMER Service de Neuroradiologie, Centre Hospitalier Universitaire F-67091 Strasbourg Cedex

Dr. SERGE PATTIN Service de Rhumatologie des Armees, H6pital Begin F-94160 Saint-Mande

Translator

MARIE-THERESE W ACKENHEIM Institut de Radiologie, Universite de Strasbourg, II, rue Humann F-67085 Strasbourg Cedex

The cover design shows a classical algodystrophy of the wrist and of the hand

ISBN-13: 978-3-642-67991-9 DOl: 10.1007/978-3-642-67989-6

e-ISBN-13: 978-3-642-67989-6

This work is subject to copyright. All rights are reserved, whether the whole or part of the material is concerned, specifically those of translation, reprinting, re-use of illustrations, broadcasting, reproduction by photocopying machine or similar means, and storage in data banks. Under § 54 of the German Copyright Law where copies are made for other than private use a fee is payable to "Verwertungsgesellschaft Wort", Munich.

© by Springer-Verlag Berlin Heidelberg 1981

Softcover reprint of the hardcover 1st edition 1981

The use of registered names, trademarks, etc. in this publication does not imply, even in the absence of a specific statement, that such names are exempt from the relevant protective laws and regulations and therefore free for general use.

Reproduction of the figures: Gustav Dreher GmbH, Stuttgart

2127/3130-543210

Foreword

It is with great pleasure and ,much interest that I accepted to write the foreword to this book by Paul Doury, Yves Dirheimer, and Serge Pattin on the subject of "algodystrophy." First, because I know the extent of their personal experience, from which they have selected the best for this book. Second, because it seemed to me that their detailed analysis of the numerous works on the subject, works which have been published all over the world and which provide diverse physiopathologic interpretations, would provide a comprehensive study meeting a real need.

Algodystrophy, to adopt the term used by the authors, merits rheumatolog­ists' careful attention. It is indeed a frequent condition and, as is now well known, occurs in the most varied etiologic circumstances; it is not solely posttraumatic, a notion on which diagnosis had long been based. This variable etiology suggests the complexity of algodystrophy's pathogenic mechanism.

The condition usually shows a pseudoarthritic inflammatory pattern and/or localized and painful demineralization of the bones, which naturally leads the patient to consult a specialist. Recently much has been learned about algodystrophy, on the one hand as a result of modern investigation techniques such as bone scintigraphy, which make possible a more accurate diagnosis of the early stages or of the localized forms of the disease, and, on the other hand, with regard to the possibilities of a better adapted therapy, liable to modify markedly the evolution of the disease. The opening chapter of this book demonstrates the recent escalation of progress in this field.

This brief preface can unfortunately not provide an exhaustive account of the authors' personal contribution. I would, nevertheless, like to place special emphasis upon their essential conceptions. I feel that their governing thought has been to show the basic unity of the various types of algodystro­phy, the clinical features and the mode of occurrence of which are so variable that one cannot wonder that so many authors have attempted to dismember this pathologic group and to individualize several related but nevertheless distinct entities. Doury, Dirheimer, and Pattin's approach is quite different and leads them to investigate uniting characteristics found in the fields of physiopathology and pathology and in the clinical picture of algodystrophy.

First of all, what is the genesis of this painful condition and of the trophic changes that characterize it? Many factors, from almost all fields of medicine and of surgery, seem to provoke or to favor algodystrophy. It seems, however that this condition never has one particular cause, but that it is nearly always the result of several pathogenic mechanisms occurring on receptive ground. This explains the absence of a strict or exclusive parallelism between the provoking or favoring factor and the resulting symptomatic and evolutive patterns. This is particularly so in cases following trauma, since the latter can be of vastly differing nature and severity, and it is far from true that the most severe always cause the most severe and most extended algodystrophic

VI Foreword

syndrome. The posttraumatic forms are considered to be the consequence of a pathologic reflex leading to direct lesion of the cutaneous, subcutaneous, muscular, tendinous, capsular, or bony tissues, or to the development of a large locoregional vascular disturbance with a complex evolution responsi­ble for multiple alterations. - But it seems that such a reflex mechanism can also be the consequence of very diverse and non traumatic affections of the locomotor apparatus or of visceral, coronary, mediastinal, and pleuro­pulmonary irritative stimuli. This mechanism can be determined or governed by central nervous system lesions or by neurosympathetic disturbances. Also involved are biochemic agents, such as serotonin, liable to be mobilized by metabolic disturbances or drug intoxications. Many unknowns still persist on the nature and evolution of the pathogenic process of algodystrophy, but it is very likely that there is a common response pattern to these very diverse stimuli.

A critical analysis allows the authors to describe a general symptomatology which is common to the different varieties of algodystrophy. They also under­line the importance they attach to this unity by devoting a chapter to the general data on which the diagnosis of algodystrophy is based: - A clinical syndrome comprising painful, mechanical, and inflammatory

or mixed manifestations which affect more or less intensely the articular regions and are sometimes accompanied by synovial effusion of the me­chanical type;

- Absence of any biologic changes of an inflammatory type; - Radiologic changes not involving the interspaces and consisting predomi-

nantly of locoregional demineralization in differing degrees and times of occurrence;

- Almost constant and usually early occurring increased uptake of isotopes. This is, of course, not a specific but nevertheless a significant sign, especially when there is no radiologic evidence of the changes, in contrast to the clinical findings; A very peculiar cyclic development leading to spontaneous regression of the pseudoinflammatory clinical syndrome and of the scintigraphic and radiologic anomalies, occurring slowly with sometimes very marked tendinoaponeurotic sequels. Quite naturally~ this comprehensive study has led the authors to elaborate

diagnostic criteria, the value and usefulness of which they have pertinently established. All this is the result of a detailed study of all clinical types of algodystrophy aimed at throwing light on the less well-known pecularities of the most classic forms as well as describing the hitherto undescribed features of the disease. The authors' personal experience makes this chapter a very original contribution. The description of the radiologic and scintigraphic anomalies is very carefully given, and abundant and accurate illustrations of remarkable quality are provided, for which the Editor must be congratulated.

In spite of their concern to demonstrate the unity of the disease, the authors also emphasize its polymorphism and describe in detail its many clinical forms, particularly their topography, evolution, symptomatology, and etiology. They thus draw attention to the localized variants of the algodys­trophic syndrome, involving only the coxofemoral area and the knee. The latter forms, the diagnosis of which is difficult, have been made known thanks to the authors' personal studies. Equally fascinating is the description of the atypical evolutive forms, such as those which are immediately plurifo­cal, in a patent or latent manner, or secondarily plurifocal, in an extensive or recurrent way.

Foreword VII

Finally, the authors rightly emphasize the incomplete or atypical forms, hyperinflammatory or pseudophlegmonous forms, and fibrous or pseudo­sclerodermal forms, demonstrating the extreme variability of the clinical fea­tures of the disease without casting doubt upon its fundamental unity. This polymorphism justifies the comprehensiveness of the chapter on differential diagnosis, which makes reference not only to the effusional type of rheumatic disease but also to the many conditions which may mimic, clinically or radiologically, some of the features of algodystrophy in their classic forms or in their unusual aspects.

Trauma remains by far the most frequent cause of algodystrophy, but several diseases as well as certain drugs can also be held responsible, as has already been shown. This has very important theoretical and practical implications. The authors have made a detailed review of such facts, providing an exhaustive summing up of all the available data.

The reader will also be interested by the other chapters of this book, for instance the pathologic study which includes an original description of a synovial involvement. The latter is all the more interesting as such documen­tations are very rare.

Finally, the treatment of algodystrophy has been dealt with in detail; the authors describe the drug and physical treatments which are applied simultaneously and the results which can be expected. Neither prevention nor medicolegal considerations are neglected, proof that Doury, Dirheimer, and Pattin wish to provide their readers with a complete handbook, combin­ing theoretical data and the most useful practical indications. We can but congratulate them on their eclecticism and wish their book the success it deserves.

J. VILLIAUMEY

Acknowledgements

We are grateful to Prof. J. Villiaumey, president of the French Society of Rheumatology for having accepted to write the foreword for this book.

We wish to thank Prof. A. Wackenheim, Head and Chairman of Radiology, University of Strasbourg for his advices and constant support.

We thank also Mrs. M.-Th. Wackenheim for her English translation of our text and for her kindness and disponibility.

Many people in a variety of ways have made this volume possible and it gives us pleasure to identify them here: Prof. J. Arlet, rheumatology, Toulouse; Prof. R.P. Delahaye, radiology, Paris; Dr. R. Granier, nuclear medicine, Paris; Dr. L. Heraut, neurophysiology, Paris; Prof. R. Lagier, pathology, Geneva; Prof. P.J. Metges, radiology, Paris; Prof. P. Meunier, rheumatology, Lyon; Dr. B. Moyses nuclear medicine, Strasbourg; Dr. A. Norton, general practitioner, London; Dr. A. Ramsheyi, general practitioner, Teheran.

We thank also our technical assistants Mrs. C. Butterlin, L. Fischer, M. Reinheimer, R. Walter.

P. DOURY

Y. DIRHEIMER

S. PATTIN

Contents

Introduction

Chapter 1 Historical Review .... Chapter 2 Why Study this Condition?

Part 1 Symptomatology

Chapter 1 General Data in Algodystrophy

A. Clinical Syndrome . . B. Biochemical Syndrome C. Radiological Syndrome D. Scintigraphic Syndrome E. Clinical Course

Chapter 2 Clinical Description Chapter 3 Topographic Forms

A. Algodystrophy of the Upper Limb

I. Onset ......... . II. First Stage . . . . . . . .

1. Involvement of Hand and Wrist 2. Involvement of the Shoulder

III. Second Stage . . . 1. Hand and Wrist 2. Shoulder 3. Elbow .....

IV. Evolution V. Topographic Forms

1. Isolated Involvement of the Hand 2. Isolated Involvement of the Shoulder 3. Associated Involvement of the Elbow 4. Associated Involvement of the Sternoclavicular

Articulation .............. . 5. Algodystrophy Localized to Two or Three Fingers

of One Hand ....... . 6. Bilateral and Extensive Forms

B. Algodystrophy of the Lower Limbs I. Algodystrophy of the Foot

II. Algodystrophy of the Knee 1. The Classical Form . . 2. Partial Algodystrophy . 3. Highly Localized Algodystrophy

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III. Algodystrophy of the Hip 1. General Data 2. Clinical Signs 3. Clinical Course

C. Algodystrophy of the Spine D. Other Localizations

Part 2 Complementary Investigations

Chapter 1 Biochemistry

A. Nonspecific Indicators of Inflammation . . . . . . B. Calcium and Phosphorus Levels in Blood and Urine C. Calcitonin Test ..... . D. Hydroxyproline in the Urine E. Parathormone F. HL-A Antigen . . G. Synovial Fluid . . H. Muscular Enzymes

Predisposition to Algodystrophy in Certain Preexisting Metabolic Disturbances . . . . . .

1. Diabetes Mellitus 2. Hyperlipidemia

Chapter 2 Radiology . . . .

A. Techniques ..... .

I. Magnification Radiology II. Tomography ....

III. Xeroradiography IV. Electron Radiography V. Logetronography

B. Involvement of Soft Tissues C. Involvement of Bone . . .

I. Elementary Radiographic Signs 1. Osteopenia . . . . . . . . 2. Subchondral Lysis .... 3. Resorption of Cortical Bone 4. Juxta-articular Erosions

II. Association of Primary Lesions Producing Different Types of Image . . . . .

III. Evolution Features .......... . 1. Early Demineralization ...... . 2. Evaluation of the Radiologic Intensity of

Algodystrophy . . . . . . . . . . . 3. Classification into Stages ..... . 4. Forms Without Bone Demineralization

D. Topographic Forms ........... .

I. Partial Algodystrophy . . . . . . . . . II. Highly Localized or Parcellar Algodystrophy

III. Algodystrophy of the Upper Limb IV. Algodystrophy of the Foot V. Algodystrophy of the Knee . . . .

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Contents

VI. Algodystrophy of the Hip VII. Algodystrophy of the Spine

E. Articular Involvement F. Arthrography . . . . G. Arteriography . . . . H. Pertrochanteral and Intra-femoral-head Phlebography

Chapter 3 Scintigraphy

A. Bone Scanning .

I. Technique II. Results

1. Increased Uptake 2. Iso and Hypofixation 3. Usefulness of Bone Scanning for Diagnosis

of Algodystrophy . . . . . . . 4. Limits of Bone Scanning . . . . . 5. Significance of Scintigraphic Data .

B. Isotopic Exploration of the Vascular Sector C. Isotopic Exploration of the Interstitial Area D. Joint Scanning . . .

Chapter 4 Densitometry Chapter 5 Thermography Chapter 6 Vascular Investigations

A. Oscillometry . B. Capillaroscopy . . . . . C. Doppler Effect . . . . .

Chapter 7 Electromyography Chapter 8 Pathology

A. Synovia. B. Cartilage C. Bone ..

I. Macroscopy II. Microscopy

III. Electron Microscopy IV. Microradiography . . V. Static and Dynamic Histomorphometry

VI. Attempt at a Histodynamic Interpretation of the Algodystrophic Mechanism

D. Periarticular Tissues .....

I. Capsule . . . . . II. Aponeuroses, Bursae and Tendons

III. Muscles . . . . . IV. Cutaneous Tissues V. Vessels

VI. Nerves

Part 3 Clinical Forms

Chapter 1 Topographic Forms Chapter 2 Evolutive Forms .

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A. Initial Plurifocal Forms

1. Patent Forms . . 1. In the Upper Limb 2. In the Lower Limb 3. Simultaneous Involvement of the Four Limbs

II. Latent Forms

B. Secondarily Extensive Forms C. True Recurrent Forms D. Partial Forms

1. Radial Forms II. Zonal Forms

E. Parcellar Forms

Chapter 3 Incomplete Forms

A. Clinical . . . B. Radiological . . . . . C. Scintigraphic ....

Chapter 4 Atypical Forms

A. Hyperinflammatory Forms B. Pseudophlegmonous Forms C. Fibrotic Forms (Pseudo-Dupuytren) D. Pseudosclerodermic Forms ....

Part 4 Differential Diagnosis

Chapter 1 Inflammatory Process

A. Synovitis B. Phlebitis

Chapter 2 Infection

A. Osteitis . . . . B. Abscesses . . . C. Septic Arthritis

Chapter 3 Tumors .

A. Benign Tumors B. Malignant Tumors

Chapter 4 Bone Necrosis Chapter 5 Arthrosis Chapter 6 Miscellaneous

A. Fatigue Fractures B. Chondromatosis - Osteochondromatosis C. Dupuytren's Contracture D. Dupuytren's Disease of the Foot E. Scleroderma . . . . . . . F. Osteolysis . . . . . . . . . .

1. Idiopathic Osteolysis II. Idiopathic Aero-osteolysis

III. Secondary Osteolysis

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Contents

G. Osteoporosis Following Immobilization H. Posttraumatic Paget's Disease . . . . 1. Sprains . . . . . . . . . . . . . .

K. Somatic Conversion Syndromes: Hysteria

Part 5 Positive Criteria

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Clinical Criteria 102 Radiological Criteria 102 Biochemical Criteria 102 Scintigraphic Criteria 102 Criteria Related to the Clinical Course and to the Treatment 103

Part 6 Etiology

A. General Etiologic Circumstances 106

1. Age . . . . . . 106 II. Sex . . . . . . 106

B. Favoring Circumstances 106

1. Traumatism 106 1. The Severity of the Causal Traumatism 107 2. The Nature of the Traumatism . . . . 107 3. The Site of the Traumatism ..... 107 4. Algodystrophy of the Limbs and Immobilization 108

II. Nontraumatic Affections of the Locomotor Apparatus 108 III. Diseases of the Nervous System . . . . . 108

1. Involvement of the Peripheral Nerves 108 2. Diseases of the Central Nervous System 109

IV. Cardiovascular Diseases 109 V. Pleuropulmonary Diseases 109

VI. Hyperthyroidism 110 VII. Diabetes Mellitus . . . . 110

VIII. Hyperlipidemia . . . . . 110 IX. Iatrogenic Algodystrophies 110

1. Phenobarbitals 110 2. Tuberculostats III 3. Pregnancy . . 112

X. Other Etiologic Factors 112 XI. Apparently Primary Algodystrophies 112

XII. Etiologic Factors in Our 250 Cases of Algodystrophy 113

Part 7 Physiopathology

Part 8 Treatment

Chapter 1 Chemotherapy

A. Analgesics .......... . B. Nonsteroid Anti-Inflammatory Drugs C. Systemic Corticosteroids D. Local Corticosteroids . . . . . E. Therapy Aimed at Vasodilatation

I. Systemic Treatment 1. Alpha-blockers . . . .

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2. Ganglioplegics . . . . 3. Postganglionic Blockers

II. Local Treatment

F. Griseofulvin . G. Beta-blockers H. Calcitonin . .

Chapter 2 Physical Treatment

A. Massage ...... . B. Hydrotherapy, Crenotherapy, Thalassotherapy C. Kinesitherapy and Rehabilitation D. Electrotherapy . E. Roentgentherapy F. Acupuncture

Chapter 3 Surgery . Chapter 4 Management of A1godystrophies Chapter 5 Prevention ..... .

Part 9 Clinical Course and Prognosis

Chapter 1 Clinical Course

A. Clinical Course of Untreated Algodystrophy B. Clinical Course of Treated Algodystrophy

Chapter 2 Prognosis

Part 10 Medicolegal Considerations

Causality ........ . Past Status . . . . . . . . . Duration of Total Transient Disability Date of Consolidation . . . . . . . Fixation of Permanent and Partial Disability The Pretium Doloris

References . .

Subject Index.

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