Identifying Data

A case of Lorna B. Ulbata, 56 years old, female, single,

Filipino, Roman Catholic, presently residing at Brgy. Cancayang, Javier Leyte, admitted for the 1st time at RTRH.

Chief Complaint

Right Hand Swelling

History of Present Illness

2 months PTA

Patient accidentally slide and her right hand first touch the ground which supported the whole body (+) swelling of the hand (+) pain with pain scale of 7 out of 10 Went to manghihilot for 9 sessions with increase of swelling noted and was prescribed with Cefalexin BID x 15 days

History of Present Illness

3 weeks PTA

Still with swelling of the right hand & burning pain sensation radiating to the forearm and to the elbow Consultation done at Abuyog District Hospital Right hand x-ray was done Impression: complete fracture of the right distal radial bone with callus formation

History of Present Illness

1 Week PTA

With restrictions in the shoulder movements (especially abduction) noted Impossible to make a fist Consultation done to a private physician Medications: Alenpronale (Revanta) Celecoxib 200mg 1 capsule Calcium+Vitamin D (Calci Pluc) 1 tab Less relief of pain & swelling noted

Past Medical History

Past Hospitalization: 2009: gastric ulcer at Abuyog District Hospital

Psychosocial History
Patient is a self-employed
Commerce Graduate A non-smoker

Non-alcoholic beverage drinker

Review of System

General: No weight Loss, no body Malaise Skin: shiny, swelling right hand Head: no headache, no lightheadedness, no dizziness Eyes: no pain, no redness Ears: no earache, no discharges Nose & Sinuses: no congestion, no nasal stuffiness Mouth & Throat: no sorethroat, no bleeding gums Neck: no pain, no rigidity Respiratory: no dyspnea, no hemoptysis, no orthopnea Cardiovascular: no chest pain, no palpitatons GIT: good appetite, no nausea, no vomiting GUT: no hematuria, no polyuria, no dysuria, no oliguria Musculoskeletal: with muscle & joint pain at the right hand

Physical Examination
Patient was conscious, coherent, oriented to time,

place & person, afebrile, mesomorph, well developed, well nourished, not in cardiorespiratory distress with the following vital signs: BP- 140/90 mmHg HR 112 bpm RR 24 cpm Temperature 36.4

Physical Examination
Skin:
Inspection: brown complexion, with swelling & shiny

on the right right hand Palpation: warm, hyperhidrosis, with good skin turgor Nails: pinkish nail beds with good capillary refill (<2 seconds), without clubbing or cyanosis

 Head:

skull is normocephalic, black long hair equally distributed, temples not depressed, no nits, no scalp lesionno tenderness Eyes: Eyebrows: symmetric, black hair, no lesions, no scars Eyelashes: fine black hair, ectropion Eyelids: no lidlag, no ptosis, no edema, no swelling, no scars Conjunctiva: pinkish palpebral conjunctiva, no hemorrhages, no active lesions, no ulcerations Sclera: anicteric, no hemorrhage, no active lesions Cornea, Iris, Lens: with opacity, no active lesions, no lacerations or serrations Pupils: round, asymmetrical, 2-3mm in diameter from normal to constriction, briskly reactive to direct and consensual light stimulation EOM: full

 Ears: symmetrical, no impacted cerumen, no discharges, hearing not

impaired,no tenderness Nose and Sinuses: pinkish mucous membrane, septum at midline, no discharges, no congestion, no nasal flaring, no sinus tenderness Mouth and Throat: Lips: symmetrical, pinkish in color, no lesions, no cheilosis, and no angular deviation Buccal mucosa: pale, moist mucous membrane, no lesions Teeth: complete set of teeth, no false dentures Gingiva: no swollen gums, uvula at midline Tonsils: no enlargement, no redness, no abscess Neck:supple, trachea at midline Breast: symmetrical, no lesions, no discharges, no lumps, no palpable lymph nodes, no tenderness

 Chest and Lungs:

Inspection: symmetrical lung expansion, no lagging, no

subscapular and intercostal retraction on respiration Palpation: confirmed symmetrical chest expansion, unimpaired tactile fremitus, no masses, no tenderness Percussion: resonant in all lung fields Auscultation: no crackles, no wheezes, no pleural friction rub Cardiovascular: Inspection: adynamic precordium, no precordial bulging, no visible pulsation, PMI at 5th ICS left midclavicular line Palpation: PMI noted at 5th ICS left midclavicular line, no heaves, no thrills, no tenderness Auscultation: regular rhythm and synchronous with pulse rate, no murmurs, no pericardial friction rub

 Abdomen:
Inspection: globular, no visible peristalsis, no engorged vein,

no hypo/hyperpigmentation Palpation: no tenderness, no mass, liver not enlarged, kidney not palpable Percussion: tympanitic all over Auscultation: normoactive bowel sounds, no arterial bruit, no venous hum, no peritoneal friction rub

Extremities:
Range of Motion Shoulder Flexion Extension Abduction Adduction Internal Rotation 60 degrees 10 degrees PE Right Shoulder 80 degrees 15 degrees

PE Left Shoulder

PE Right Shoulder

PE Left Shoulder

180 degrees 80 degrees 90 degrees 90 degrees 55

4/5 4/5 3/5 4/5 3/5

5/5 5/5 5/5 5/5 5/5

External Rotation

10 degrees

45 degrees

4/5

5/5

Extremities:
ROM of the Elbow Flexion Right elbow 150 degrees Left Elbow 150 degrees Right elbow 4/5 Left Elbow 5/5

Extension

- 10 degress

10 degrees

4/5

5/5

Supination

5 degrees

80 degrees

3/5

5/5

Pronation

70 degrees

80 degrees

4/5

5/5

Extremities:
ROM of the Wrist Right Wrist Left Wrist Right Wrist Left Wrist

Flexion Extension Adduction (Radial deviation ) Abduction (Ulnar Deviation)

20 degrees 20 degrees 5 degrees

80 degrees 70 degrees 20 degrees

3/5 3/5 3/5

5/5 5/5 5/5

5 degrees

30 degrees

3/5

5/5

Extremities:
ROM of the fingers & Thumb First interphalangeal flexion Second, third, and fourth interphalangeal flexion Right 10 degrees 10 degrees Left 80 degrees 100 degrees

Sensory
Sensation Testing C5 C6 C7 C8 T1 Lateral side of the antecubital fossa Thumb Middle Finger Little finger Medial side of the antecubital fossa Light touch +++ +++ +++ +++ +++ Pinprick +++ +++ +++ +++ +++

Reflexes
Biceps Right Left 1+ 2+ Triceps 1+ 2+ Brachialis 1+ 2+ Knee 2+ 2+ Ankle 2+ 2+

Neurologic Exam:
MENTAL STATUS EXAM: alert, coherent and oriented to person, place, and time, no mental changes and confusion noted. CRANIAL NERVES: CN I: no anosmia CN II & III: pupils 2-3 mm in diameter, symmetrical, equally reactive to direct and consensual light stimulation CN III, IV, VI: able to move eyes upward, downward, medially and laterally CN V: intact sensory function to pain and touch, with intact corneal reflex CN VII: able to smile, able to frown CN VIII: responsive to verbal stimuli CN IX and X: with intact gag reflex, able to swallow CN XI: able to turn head to both sides against resistance, able to shrug shoulder CN XII: able to protrude tongue, no deviation to L/R

Course in the Wards

Admission
1stst HOSPITAL DAY Motor: increase of the ROM of the shoulder Less swelling 2nd HOSPITAL DAY Motor: increase of the ROM of the shoulder No swelling

Diagnostics Procedure
Results
Hemoglobin Hematocrit WBC Neutrophils Lymphocytes Monocytes 150 0.42 7.85 0.72 0.27 0.01

Salient Features
1. 2. 3. 4. 5. 6. 7.

56 years old Female Single Swelling of the right hand Injury of the right hand for about 2 months ago Continuous Burning Pain radiating to the forearm & elbow Decreased ROM of the right shoulder, elbow, wrist, fingers & thumb
Restriction of right shoulder movement With restrictions in the shoulder movements (especially abduction) noted Impossible to make a fist

8.

Hyperesthesia, allodynia, hyperhidrosis

NERVE ENTRAPMENT/ COMPRESSION SYNDROMES

Rule In 1. 2. 3. Swelling of the right hand Injury of the right hand for about 2 months ago Continuous Burning Pain Rule Out 1. Continuous Burning Pain radiating to the forearm & elbow 2. Decreased ROM of the right shoulder, elbow, wrist, fingers & thumb Restriction of right shoulder movement With restrictions in the shoulder movements (especially abduction) noted Impossible to make a fist

Fibromyalagia
Rule In 56 years old Female regional areas of pain Rule out 11/18 tender point Related to sleep, problems anxiety or depression

Posttraumatic neuralgia
Rule In 1. 2. Injury of the right hand for about 2 months ago Decreased ROM of the right shoulder, elbow, wrist, fingers & thumb Continuous Burning Pain Weakness of the right hand Rule Out 1. Swelling of the right hand 2. progressive spread of symptoms. 3. obtain relief with sympatholytic procedures

3. 4.

COMPLEX REGIONAL PAIN SYNDROME (CRPS)

RULE IN 1. 2. 3. 4. 5. 6. 7. 56 years old Female Single Swelling of the right hand Injury of the right hand for about 2 months ago Continuous Burning Pain radiating to the forearm & elbow Decreased ROM of the right shoulder, elbow, wrist, fingers & thumb Restriction of right shoulder movement With restrictions in the shoulder movements (especially abduction) noted Impossible to make a fist 8. Hyperesthesia, allodynia, hyperhidrosis RULE OUT

ANATOMY & PHYSIOLOGY

Brachial Plexus

CRPS
is a neuropathic pain syndrome characterized by

autonomic dysfunction and severe pain that may lead to crippling contractures of the limbs. A variety of painful conditions following injury which appears regionally having a distal predominance of abnormal findings exceeding in both magnitude and duration the expected clinical course of the inciting event, often resulting in significant impairment of motor function and showing variable progression over time

CRPS
COMPLEX varied and dynamic clinical presentation
REGIONAL non-dermatomal distribution of the

symptoms PAIN out of proportion to the inciting events SYNDROME constellation of symptoms and signs

International Association for the Study of Pain (IASP) Nomenclature

CRPS I = reflex sympathetic dystrophy
CRPS II = causalgia

A.K.A = algodystrophy, shoulder-hand syndrome,

Sudeck's atrophy, transient osteoporosis and acute atrophy of bone

CRPS
Female to male ratio: 3:1
Any age, but middle age predominates (median 42

years old) Onset 9-85 years old CRPS occurs in about 1-2% of patient who have had fractures and in approximately 2-5 % of patients after peripheral nerve injuries

Clinical Manifestation
1.

Pain

Continuous , constant, burning, aching, throbbing Disproportionate to the injury Asymmetrical and not in distributuion of a peripheral nerve, worst in distal

2. Autonomic abnormalities Vascular: hot swollen erythematous/cold, blached & mottled Sudomotor: Hyperhydrosis

Clinical Manifestation
1.

Motor

Diffuse weakness of the extremity

2. Trophic changes Nail growth Loss of function: muscle, joints & tendon Hair changes (coarse/loss of hair) Skin-thin and glossy, loss of elasticity osteoporosis

CRPS I
The presence of an initiating noxious event or a cause of immobilization 2. Continuing pain, allodynia or hyperalgesia with which the pain is disproportionate to the inciting event. 3. Evidence of some time of edema, changes in skin blood flow or abnormal sudomotor activity in the region of pain 4. The diagnosis is excluded by the existence of conditions that would otherwise account for the degree of pain & dysfunction
1.

CRPS II (Causalgia) Criteria

The presence of continuous pain, allodynia or hyperalgesia after a nerve injury, not necessarily limited to the distribution of the injured nerve 2. Evidence of some time of edema, changes in skin blood flow or abnormal sudomotor activity in the region of pain 3. The diagnosis is excluded by the existence of conditions that would otherwise account for the degree of pain & dysfunction
1.

Pathophysiology Unknown
3 main hypotheses Facilitated neurogenic inflammation Autonomic dysfunction Neuroplastic changes within the CNS

Treatment Goals
Relief of pain
Return of function Prevent or slow the progression

Treatment
Physical Therapy 2. Pain
1.

Eterocoxib 120 mg 1 tab OD NSAIDs

3. Steroids 4. Gabapentin & Pregabalin 5. Calcitonin

Sympathetic Blockade
Lumbar sympathetic block
Stellate ganglion block IV regional anesthesia block