Compartment

syndrome and
CRPS
 Hand compartment syndrome
 Common causes
 Burns, high pressure injection injuries ( A-line or IV inflitrations), skeletal trauma, crush injuries
 Symptoms: non specific aching of palm, pain out of proportion, pain with passive stretch
of thumb, limited digital motion, paresthesias, absent pulses
 May present as intrinsic minus position
 Forearm compartment syndrome presents with pain with passive extension of fingers.
 Total 10
 Perform fasciotomies if
absolute pressure
>30mm Hg or within
30mm Hg of Diastolic
pressure
 May require both dorsal
and volar incisions. +/-
carpal tunnel release.
 x
 x
Forearm- Volar & dorsal incision

 x
Volkman’s ischemic contracture

 2/2 irreversible muscle necrosis

 Elbow is flexed, forearm pronated, wrist flexion, thumb adduction,
MCP extension, IP flexion
 CRPS (complex regional
pain syndrome)
 During the Civil War it was seen that soldiers who
suffered missile injuries developed a neuropathic pain
that was termed "causalgia" by Silas Weir-Mitchell.
 In 1940s the term of reflex sympathetic dystrophy
came into use relating the belief of an abnormal
efferent reflex from the sympathetic nervous system to
bodily injury.
 Since that time much study and frustration has come
from this relatively rare condition
 CRPS is rare, but has started to see an increase in dx.
Common causes

 Crush injury

 surgery

 prolonged immobilization

 possible malingering
Presentation
 Often seen after injury to a limb or related to some inciting event.
 Patient complains of skin color/ temperature/ appearance changes in the
affected limb. Vasomotor changes: edema, sweating, nail changes.
 Pain often excruciating – burning or stinging (87% of cases) tingling,
electric-like, etc. are often symptoms that patients feel. The pain is often
out of proportion to stimulus or the event (69%).
 Muscle spasms
IASP (International Assoc for the Study of Pain) diagnostic
criteria include 4 subjective and/ or objective findings:

 1. The presence of an initiating event or a cause of

immobilization – peripheral injury or central (stroke, etc)*.
(Injury)
 2. Continuing pain, allodynia, or hyperalgesia in which the
pain is disproportiate to inciting event. (Sensory)
 3. Evidence of edema, changes in skin blood flow, or
abnormal sudomotor activity in region of pain. (Vasomotor)
 4. Diagnosis is excluded by the existence of other
conditions that would otherwise account for the degree of
pain/ dysfunction.

One symptom from each category and at least one sign

from 2 categories must be evident to diagnose CRPS, at
least by research criteria.
 CRPS I: No obvious nerve lesions. Majority of patients. This is the less
painful, debilitating of the two. From trauma, cast or tight dressings.
 CRPS II (causalgia) is related to a known injury to a specific major
nerve with neuropathic pain frequently following along the
distribution of that nerve alone, though not always.
 More debilitating that type I
 Can also be associated with hypoesthesia
 Treatment
 Functional restoration of affected limb - often should be considered
first before other treatments
 Sympathetic and/or motor blocks
 Cognitive behavioral techniques
 Psychotherapy
 Pharmacotherapy
 Occupational therapy
 Physical therapy
 Surgery: eg CTR
 x
 Functional restoration
 Functional restoration involves steady progression
from gentle movementsgentle, weight bearing
movement.
 Results in more active load bearing with expected
gradual desensitization and increased functionality of
limb.
 Examples include moving from silk stimulation to other
cloths and textures,
 the scrub and carry technique- active movement and
compression, few times a day, initially increases
symptoms but decreases over time. Inhibits muscle
guarding and atrophy. Carrying entails gradually
increasing the loads or weight on affected extremity.
 contrast baths that widen the temperature range that
the patient can tolerate.
 x
Pharmacotherapy

Pharmacotherapy is often on a trial and error basis

-no RCT evidence that these work but it is tailored to every patient
-Gabapentin, pregabalin, TCAs are first line treatments
 SSRIs and SNRIs like fluoxetine and duloxetine are also often used
 Opioids should be avoided as much as possible as their
effectiveness is not well proved and dependence/ addiction are
serious concerns in CRPS patients.
Prognosis

 Poor
 Many report extreme lack of satisfaction with their pain control and
are usually disabled.
 More research in pain management and multi-modal therapies for
CRPS is needed.
 Prevention: vitamin C 500 mg daily x 50 days in distal radius
fractures treated conservatively (conflicting evidence*)
 Avoid tight dressings and prolonged immobilization