Makindo Medical Notes

CRPS is a chronic pain disorder, usually affecting a limb after trauma or surgery. It is characterised by disproportionate pain plus sensory, motor, autonomic and trophic changes. Early recognition and rehabilitation are vital to prevent long-term disability.

📖 Types

• CRPS I – no identifiable nerve injury (≈90% cases).
• CRPS II – clear peripheral nerve injury.

🧬 Pathophysiology

• Peripheral & central sensitisation → exaggerated pain signalling.
• Neurogenic inflammation (substance P, CGRP, cytokines).
• Autonomic dysregulation → vasomotor + sweating abnormalities.
• Cortical reorganisation & psychological contributors.

🩺 Clinical Features

• Burning, severe pain out of proportion to injury.
• Allodynia, hyperalgesia.
• Colour/temperature asymmetry, swelling, sweating changes.
• Motor: weakness, stiffness, tremor, dystonia.
• Trophic: altered hair, nails, thin shiny skin.

📊 Diagnosis – Budapest Criteria

• Continuing pain disproportionate to inciting event.
• ≥3 symptom categories + ≥2 sign categories (sensory, vasomotor, sudomotor/oedema, motor/trophic).
• No better alternative explanation.

🛠️ Management

• Education & reassurance – explain benign but disabling nature.
• Physiotherapy – early mobilisation, mirror therapy, graded motor imagery.
• Psychological support – CBT, coping strategies.
• Pharmacology – neuropathic agents (gabapentin, amitriptyline), bisphosphonates, short steroid courses, IV ketamine/lidocaine in select cases.
• Interventions – sympathetic blocks, spinal cord or dorsal root ganglion stimulation in refractory cases.

📈 Prognosis

• Best outcomes with early diagnosis and active rehab.
• Warm/early CRPS is more reversible than chronic “cold” phase.
• Many improve within 12 months, but chronic cases may persist and cause severe disability.

📌 Summary Table

Feature	Key Points
Nature	Chronic pain syndrome, sensory + autonomic + trophic changes
Types	Type I (no nerve injury), Type II (nerve injury)
Diagnosis	Clinical, Budapest Criteria
Management	Multidisciplinary: physio, psychology, neuropathic meds, blocks, neurostimulation
Prognosis	Early intervention crucial; variable long-term outcomes

💡 Clinical Pearls

• Always suspect CRPS in persistent, disproportionate post-trauma pain.
• Do not immobilise – early mobilisation improves outcomes.
• Consider bisphosphonates if pain and bone scan activity present.
• Cold CRPS = poorer prognosis, emphasise early referral to pain specialists.

📚 References

• NHS – CRPS overview
• RCP Guideline (UK)
• Review of CRPS pathophysiology

🩺 Case Examples — Complex Regional Pain Syndrome (CRPS)

• Case 1 (CRPS type I — post-fracture): A 48-year-old woman presents with severe burning pain, swelling, and hypersensitivity in her right wrist, 6 weeks after a Colles’ fracture treated conservatively. The skin is shiny and red, with increased sweating, and she cannot tolerate light touch (allodynia). X-ray shows patchy demineralisation but no new fracture. Diagnosis: CRPS type I (no definable nerve injury, post-fracture). Management involves early physiotherapy, desensitisation exercises, neuropathic analgesics (e.g. gabapentin), and referral to a pain clinic.
• Case 2 (CRPS type II — post-nerve injury): A 35-year-old man develops severe stabbing pain, oedema, and bluish discolouration of the left foot after a laceration with confirmed tibial nerve injury. The limb is cool with trophic changes (brittle nails, hair loss). Symptoms are disproportionate to the original injury and limit weight-bearing. Diagnosis: CRPS type II (causalgia — following nerve damage). Management includes neuropathic analgesia, graded motor imagery, physiotherapy, and sympathetic nerve block under specialist pain services.