sudecks osteodystrophy

sudecks osteodystrophy by Dr. Bipul Borthakur

1. SUDECK’S OSTEODYSTROPHY By: Dr B. Borthakur Professor , Dept. Of Orthopaedics, Silchar Medical College and Hospital.

2. Defintion Chronic progressive disease characterised by an array of painful conditions that are characterised 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. The pain is regional in a specific nerve territory or dermatome . Usually have predominance of abnormal sensory, motor, sudomotor, vasomotor or trophic changes including osteoporosis.

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

4. Classification of Complex pain regional syndrome Based on the presence of nerve lesion following the nerve injury

5. Epidemiology Females more commonly affected than male. Incidence increases with age upto 70 years old. Location - 1. 60% occur in the upper extremity. 2. 40% occur in the lower extremity.

6. Risk factors Trauma with exaggerated response to any injury. Surgery. Prolonged immobilisation. Anxiety or depression. Use of ACE inhibitors at the time of trauma. History of asthma or migraines. Smoking Fibromyalgia.

7. Pathophysiology

8. Lank Ford and Evans Stages of RSD

9. Clinical features Clinical feature are in a continuum. 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 Xray Decreased sympathetic activity.

10. 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.

11. 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.

12. Diagnosis Radiographs – Osteopenia. Soft tissue swellings. Subperiosteal bone resorption. Preservation of joint spaces. Three phase bone scan. Thermography. EMG/NCV.

13. Diagnosis (contd.) Usually clinical but can be confirmed by pain relief with sympathetic block. Budapest diagnostic criteria

14. Differential diagnosis Soft tissue infections. Malingering. Psychiatric disease. Neuropathic pain. Chronic pain. Raynaud disease. Thoracic outlet syndrome. Arterial insufficiency. Erythromelalgia.

15. Treatment Prevention - Vitamin C has been shown to decrease the incidence of CRPS. Non operative- 1. Physical therapy and pharmacological treatments. NSAIDs, alpha blckers, beta blockers, Calcitonin, corticosteroids, anti arrythmics etc, 2. Nerve stimulation – mainly on the distribution of nerve. Transcutaneous electric stimulation Peripheral nerve stimulation. Spinal cord stimulation. 3. Nerve blockade- Agent used - anesthetics lidocaine , bupivacaine Stellate ganglion block for upper extremity. Lumbar spinal blockade for lower extremity.

16. Treatment (contd.) 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.

17. THANK YOU. “ dehino’sminyathā dehe kaumāraṃ yauvanaṃ jarā tathā dehāntaraprāptirdhīrastatra na muhyati ” “Just as the boyhood, youth and old age come to the embodied Soul in this body, in the same manner, is the attaining of another body; the wise man is not deluded at that .”