Can a clinical vignette be created for Complex Regional Pain Syndrome (CRPS)?

Clinical Vignette for Complex Regional Pain Syndrome (CRPS)

Yes, here is a comprehensive clinical vignette that captures the essential diagnostic and management features of CRPS:

Patient Presentation

A 42-year-old woman presents 8 weeks after a distal radius fracture (treated with casting) with severe, burning pain in her right hand and wrist that is disproportionate to the original injury. 1, 2 She describes the pain as "excruciating" and reports it has progressively worsened and spread from her wrist up to her forearm. 1, 2 Even light touch from clothing or a gentle breeze triggers intense pain (allodynia). 2

Physical Examination Findings

On examination, the right hand demonstrates:

• Temperature asymmetry: The affected hand feels warmer than the left by palpation 2
• Skin changes: Mottled, reddish discoloration with increased sweating compared to the contralateral limb 1, 2
• Edema: Diffuse swelling of the hand and fingers 2
• Motor dysfunction: Decreased active range of motion in the fingers and wrist, with weakness that appears disproportionate to expected post-fracture recovery 2
• Trophic changes: Early hair loss noted on the dorsum of the hand 1, 2
• Severe allodynia: Patient withdraws from light touch with cotton swab 2

Diagnostic Workup

The patient meets Budapest Criteria for CRPS Type 1 (no nerve injury present): 3, 4

• Continuing pain disproportionate to the inciting event
• Reports at least one symptom in three of four categories (sensory, vasomotor, sudomotor/edema, motor/trophic)
• Displays at least one sign in two or more categories on examination
• No other diagnosis better explains the signs and symptoms

Three-phase bone scintigraphy is obtained and shows increased periarticular uptake in the affected wrist and hand (sensitivity 78%, specificity 88%). 1, 2 Radiographs demonstrate early patchy osteopenia. 1

Management Algorithm

Immediate Initiation (Week 1-2):

• Physical therapy with gentle stretching, progressive tactile desensitization, and active range of motion exercises started immediately 5, 4
• Oral corticosteroids: Prednisone 40 mg daily for 5 days, then taper over 10 days 5
• Neuropathic pain medication: Gabapentin 300 mg three times daily, titrated to 900 mg three times daily over 2 weeks 4
• Acetaminophen 1000 mg three times daily for baseline analgesia 5

Week 3-4 Assessment:

Patient reports only 30% improvement in pain and continues to have significant functional limitations preventing effective physical therapy participation.

Escalation to Interventional Treatment:

• Referral to pain specialist for sympathetic nerve blockade 4
• Stellate ganglion block performed (upper extremity CRPS) as part of multimodal treatment 5
• Patient experiences 4-5 months of significant relief with improved function after series of 3 blocks 5

Week 12 Reassessment:

With combination therapy, patient demonstrates:

• 70% reduction in pain intensity
• Restoration of near-normal range of motion
• Resolution of temperature asymmetry and color changes
• Ability to perform activities of daily living
• Return to work with modifications

Critical Clinical Pearls

• CRPS does not demonstrate placebo response except at very early time points (15-30 minutes), distinguishing it from other pain conditions 1, 2
• Early aggressive treatment within the first 3 months significantly improves long-term outcomes 4
• Pain spreading to the contralateral limb can occur and represents disease progression 1, 2
• Sympathetic dysregulation is a key feature, manifesting as temperature and color changes 1
• This is a diagnosis of exclusion—rule out infection, vascular compromise, and other neurological conditions first 3, 4

Common Pitfalls to Avoid

• Delaying physical therapy due to pain severity—this creates a cycle where disuse increases pain upregulation 1
• Attributing symptoms to malingering because pain appears disproportionate to injury 4
• Stopping treatment prematurely when patient shows initial improvement—CRPS requires sustained multimodal therapy 5
• Failing to monitor for contralateral spread or progression to chronic phase (>12 months) 3
• Using opioids as first-line therapy—no FDA-approved medications exist for CRPS, and neuropathic pain agents are preferred 4