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Patient Case: Complex Regional Pain Syndrome (CRPS) type I

Patient Case: Complex Regional Pain Syndrome (CRPS) type I

Discussion

A 38-year-old woman presents to the pain clinic with severe burning pain, swelling, and skin color changes in her right hand. The symptoms began three months ago after a minor wrist fracture that healed without complications. However, the pain has progressively worsened and is now disproportionate to the original injury. She also reports increased sweating in the affected hand and extreme sensitivity to touch, making it difficult to perform daily activities.

On examination, her right hand appears slightly swollen, with a reddish-purple discoloration. The skin is warm and exhibits increased sweating. Light touch elicits severe pain (allodynia), and there is reduced range of motion due to pain. No motor weakness or sensory loss is noted, and X-rays show no evidence of new fractures or joint damage.

Based on her symptoms and clinical findings, she is diagnosed with complex regional pain syndrome (CRPS) type I, a neuropathic pain disorder often triggered by trauma. She is started on physical therapy, neuropathic pain medications (gabapentin), and graded motor imagery to improve function and prevent chronic disability.

Questions
1. What is the most likely diagnosis in this patient with severe, persistent pain and autonomic changes following a minor injury?

A) Peripheral neuropathy

B) Complex regional pain syndrome (CRPS)

C) Rheumatoid arthritis

D) Carpal tunnel syndrome

2. Which clinical feature is most characteristic of complex regional pain syndrome (CRPS)?

A) Motor weakness and sensory loss

B) Pain that is proportional to the initial injury

C) Allodynia and autonomic dysfunction

D) Joint deformities and erosion on X-ray

3. What is the first-line management approach for this patient?

A) Opioid analgesics

B) Immobilization of the affected limb

C) Physical therapy and neuropathic pain medications

D) Immediate surgical intervention

4. What is the most common triggering event for CRPS?

A) Autoimmune disease

B) Psychological stress

C) Minor trauma or fracture

D) Infectious arthritis

Reveal answers

Answers

1 - B) Complex regional pain syndrome (CRPS)

CRPS is a chronic pain condition characterized by severe, disproportionate pain and autonomic dysfunction (swelling, temperature changes, and color changes) following trauma. The lack of motor weakness or sensory loss differentiates it from neuropathy.

2 - C) Allodynia and autonomic dysfunction

CRPS is defined by neuropathic pain symptoms such as allodynia (pain from normally non-painful stimuli) and autonomic disturbances like skin color changes, swelling, and sweating abnormalities.

3 - C) Physical therapy and neuropathic pain medications

Early mobilization through physical therapy is crucial to prevent functional deterioration. Neuropathic pain medications like gabapentin, pregabalin, or amitriptyline help manage pain. Opioids and immobilization can worsen the condition.

4 - C) Minor trauma or fracture

CRPS is most commonly triggered by minor injuries such as fractures, sprains, or surgery. The pain response is exaggerated and persists beyond normal healing times.