Abstract ID: A46
Abstract Title: Is amputation an indication for severe limb CRPS type I?
Poster Type: Poster
ABSTRACT BODY
22 year-old left hand dominant, Hispanic girl presented to our pain clinic on October 17, 2001 with severe painful, erythematic, edematous, motionless left hand. She sustained a crush injury of the left hand which was caught in drive mechanism of a conveyor system while she was working as a packer on June 28, 1999. No detailed history about her prior treatment except for a recent left hand surgery of closed manipulative reduction of the lef wrist and application of long arm plaster for massive strangulation edema of the left hand with anterior medial subluxation of the wrist. The pain was described as continuous, sharp, stabbing with burning sensation and numbness, localized only in the left forearm and hand. The pain scores were 10/10 on VAS scales. Any movement of the left hand would exacerbate the pain. Patient elevated the left hand above the shoulder all the time and refused any touch of the left forearm and hand during the visits. The focal exam showed severe regional swelling and edematous left hand, about three times big in size compared to the right hand. redness, hyperkarotic, shiny scaly skin with two large blisters adjacent in the back of the hand about 3X4 cm each. Muscular atrophy, allodynia and diminished muscle strength were also noted. There were no rigidity, spasticity, and tremor. The motor and sensory functions of the left hand seemed to be intact. No left elbow and wrist reflexes were examed. Patient was significant for multiple left hand infections in the past, asthma, depression, peptic ulcer disease and possible bulimia. Past surgical history revealed childhood T&A, appendectomy at 7, right inguinal hernia repair in 1994, and a recent left hand surgery in March of 2000. The left hand plain X-ray showed no fractures or dislocation. And repeat EMG testing did not show any neurological abnormalities in her left forearm and hand. The diagnosis of CRPS type I of the left arm/hand was made based the history, clinic and laboratory findings. For the next 2 years, we had tried different therapies including left side stellate ganglion blocks twice, high doses of strong opioids, i.e., duragesic patch, OxyContin, etc., intraveous PCA, brachial plexus blocks with indwelling catheter for aggresive left hand rehabilitation, both in out- and inpatient settings. Although she had some temporaty responses to some of these therapies, she completely lost the function of the left hand. In the meantime, she consulted a few hand surgeons in town for possible amputation, the request was obviously refused. Finally, exhausted and frustrated, she went back to her country and had left hand above wrist amputation within two weeks. She returned to our clinic after the amputation and stated she was 100% pain free only with some residual stump dysthesia, and more important, much happier. Now she had a good fit prosthesis and much improved function of the left hand.
ATTACHED FILES
Reg Anesth Pain Med 2004; 29(2):A46