A 44-year-old man sought relief from severe pain, swelling, and restricted radiocarpal and digital motion of his left hand. Four months before, he had suffered a fracture of the distal radius metaphysis (Colles' fracture), which was treated by closed reduction with long-arm cast immobilization for 6 weeks.
Atrophy and stiffness are anticipated after fracture immobilization, but the burning pain, diffuse edema, vasomotor instability, and loss of joint mobility heightened suspicion of reflex sympathetic dystrophy (RSD). No radiographic abnormality is evident in nearly one third of RSD cases; however, this patient's roentgenogram revealed periarticular osteopenia with aggressive resorption of cancellous metaphyseal bone at multiple distal articulations, confirming the diagnosis.
Frequently, there is no apparent cause of RSD, although most instances of the disorder are associated with trauma. The condition also has been linked to certain drug reactions, peripheral nerve injuries, and cerebrovascular diseases. The occurrence of RSD after Colles' fracture has been estimated as 1% to 3%.1
RSD may advance through three clinical stages; this patient's symptoms are characteristic of the first stage, which can last from 3 to 6 months. Induration and dystrophic skin changes commonly occur next. Cutaneous atrophy, contractures (see page 881), osteoporosis, and persistent pain are indicative of the gradually evolving atrophic stage.
Since outcome worsens with delay of therapy, begin treatment early with analgesics or NSAIDs, range of motion exercises, and desensitization therapy. If response is poor, consider referral to an orthopedist; sympathetic ganglion blockade with an anesthetic agent, a limited course of systemic corticosteroids, or surgical intervention may be indicated.2
1. Hove LM. Nerve entrapment and reflex sympathetic dystrophy after fractures of the distal radius. Scand J Plast Reconst Surg Hand Surg. 1995;29:53-58.
2. Loren GJ. Pain and joint immobility following Colles' fracture. J Musculoskel Med. 1996;13(6):62-63.