Sudeck's osteodystrophy - Dr Bipul Borthakur

Dr. Bipul Borthakur, Professor, Department of Orthopaedics, SMCH, Silchar, Assam

1. SUDECK’S OSTEODYSTROPHY DR BIPUL BORTHAKUR PROFESSOR, DEPT. OF ORTHOPAEDICS, SILCHAR MEDICAL COLLEGE AND HOSPITAL.

2. LEARNING OBJECTIVES DEFINITION CLASSIFICATION RISK FACTORS AND PATHOPHHYSIOLOGY STAGING CLINICAL FEATURES AND DIAGNOSTIC CRITERIA MANAGEMENT

3. DEFINTION “ Chronic progressive disease with an array of painful conditions that are characterized by a continuing ( spontaneous or evoked) regional pain that is disproportionate in time or degree to the course of any known trauma or other lesion . “ Pain distributed in specific nerve territory or dermatome . Predominance of abnormal sensory, motor, sudomotor, vasomotor or trophic changes including osteoporosis.

4. SYNONYMS Complex regional pain syndrome. Reflex sympathetic dystrophy. Sudecks atrophy. Causalgia. Algodystrophy . Algoneurodystrophy . Post traumatic pain syndrome. Painful post traumatic dystrophy .

5. CLASSIFICATION

6. EPIDEMIOLOGY Females commonly affected Incidence increases with age 60% occur in the upper extremity 40% occur in the lower extremity

7. RISK FACTORS Actual cause is not known Trauma Surgery. Prolonged immobilization. Anxiety or depression. Use of ACE inhibitors at the time of trauma. History of asthma or migraines. Smoking Fibromyalgia.

8. PATHOPHYSIOLOGY

9. LANK-FORD AND EVANS STAGING

10. CLINICAL FEATURES Stage One (Acute stage – 6 to 8 weeks after inury ) Warmth, Coolness, Burning pain, Increased sensitivity to touch, Increased pain with hyperalgesia , Accelerated hair and nail growth Tenderness and stiffness of joints Bone changes on X-ray Decreased sympathetic activity.

11. Dystrophic changes. Stage 2 - Dystrophic changes Pain is constant – throbbing, burning, aching, exaggerated by stimuli. Affected limb may still have oedema , cool, mottled appearance. Nails – brittle and ridged. Pain and stiffness of joint persists. Muscle – tremor and wasting. Psychological distress sets in due to loss of pain relief. Changes in body perceptions. Increased sympathetic activity.

12. Atrophic changes Stage 3 Atrophic changes Typically the patient has had CRPS for more than 3 years. Pain is still constant Skin is cool, thin and shiny. Atrophy of limbs with contracture of joints . Muscle wasting. Increase in osteoporosis. Extreme osteopenia on xray .

13. Diagnosis Radiographs – Osteopenia. Soft tissue swellings. Subperiosteal bone resorption. Preservation of joint spaces. Three phase bone scan. Thermography. EMG/NCV. Pain relief with sympathetic block. Budapest diagnostic criteria

14. Diagnosis Cardinal signs of RSD Pain swelling Stiffness discoloration out of proportion

15. Diagnosis The diagnostic test Invasive procedure by blocking the sympathetic nerves and improvement of the symptoms

16. Diagnosis

17. DIFFERENTIAL DIAGNOSIS Soft tissue infections. Malingering. Psychiatric disease. Neuropathic pain. Chronic pain. Raynaud disease. Thoracic outlet syndrome. Arterial insufficiency. Erythromelalgia.

18. TREATMENT Prevention - Vitamin C Non operative- 1. Physical therapy and pharmacological treatments. NSAIDs, alpha blockers, beta blockers, Calcitonin, corticosteroids, anti arrhythmic drugs, mirro r box therapy sometimes help pyschologically etc ., 2. Nerve stimulation – mainly on the distribution of nerve. Transcutaneous electric stimulation Peripheral nerve stimulation. Spinal cord stimulation.

19. TREATMENT Prevention - Vitamin C Non operative- 3. Nerve blockade- Agent used - anesthetics lidocaine , bupivacaine Stellate ganglion block for upper extremity. Lumbar spinal blockade for lower extremity. 4. Oral steroids and even epidural steroid may be helpful

20. TREATMENT Chemical sympathectomy Agent used- alcohol and phenol. Operative Management – Surgical sympathectomy – ideal for patients who had a response to sympathetic block. Methods- a. Excision b. Electrocautery .

21. TREATMENT Sometimes patient explains the severe pain in a particular area Examples like release of carpal tunnel, may remarkably improve this situation Painful triggering point

22. PROGNOSIS E IF TREATMENT STARTED - WITHIN FIRST 3 MONTHS – GOOD PROGNOSIS DELAYED TREATMENT – BAD PROGNOSIS DUE TO QUICK SPREAD TO ENTIRE LIMB RESULTING IN IRREVERSIBLE CHANGES IN BONE, NERVE AND MUSCLE LIMB RESULTING IN IRREVERSIBLE CHANGES IN BONE, NERVE AND MUSCLE

23. THANK YOU