Handchirurgie, Mikrochirurgie, plastische Chirurgie : Organ der Deutschsprachigen Arbeitsgemeinschaft für Handchirurgie : Organ der Deutschsprachigen Arbeitsgemeinschaft für Mikrochirurgie der Peripheren Nerven und Gefässe : Organ der Vereinigung der Deutschen Plastischen Chirurgen
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Knowledge about the pathophysiology underlying the complex regional pain syndrome (CRPS) has increased over the last years. Classically, CRPS has been considered to be mainly driven by sympathetic dysfunction with sympathetically maintained pain being its major pathogenetic mechanism. Currently, the disease is understood as result of a complex interplay between altered somatosensory, motor, autonomic and inflammatory systems. ⋯ These pathophysiological ideas do not exclude each other. In fact they complement one another. The variety of the involved systems may explain the versatile clinical picture of CRPS.
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The main symptoms of excruciating pain, trophic and inflammatory changes, as well as functional impairment of limbs are the hallmark of the complex regional pain syndrome (CRPS). While functional impairments have to be treated by physical and occupational therapy, the former three symptoms are amendable to drug treatment: antidepressants, antiepileptic drugs and opioids are the most important drug classes for alleviating neuropathic pain whereas acute nociceptive pain may be positively influenced by non-steroidal anti-inflammatory drugs and steroids. ⋯ The use of sympatholytic agents beyond locoregional anesthesia techniques (which are covered elsewhere in this issue) is not unequivocal. In general, the evidence level for treatment strategies specifically for the complex regional pain syndrome is very poor; most recommendations and algorithms rely on results derived from studies testing drugs against other conditions where chronic (neuropathic) pain is prevalent, like diabetic polyneuropathy or postherpetic neuralgia, or medications are used on the basis of pathomechanistic considerations.
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Handchir Mikrochir Plast Chir · Feb 2010
Case Reports[The primarly overlooked scaphoid fracture--a diagnostic challenge?].
Scaphoid fractures represent the most common carpal bone fractures. These fractures may be overlooked due to insufficient diagnostics and lead to non-union and disability. A standardized diagnostic procedure with X-ray examinations, CT scans and/or MRI is recommended. We report on a case where a scaphoid fracture was overlooked, probably because of an incorrect technique of the computed tomography. ⋯ Early diagnosis and a correct description of the fracture pattern are of high value in the treatment of scaphoid fractures. X-rays combined with a CT scan or an MRI scan of the affected wrist are considered as the diagnostic standard. The reported case demonstrates that even with a thin thickness layer CT scan in axial planes, a scaphoid fracture can be overlooked. Therefore we recommend after primarily inconspicuous X-rays a CT scan with primary -oblique-sagittal layers in the longitudinal axis of the scaphoid. If this shows no fracture and the clinical suspicion persists, an MRI scan should be performed.
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Handchir Mikrochir Plast Chir · Feb 2010
[Increased sympathetic activity assessed by spectral analysis of heart rate variability in patients with CRPS I].
The complex regional pain syndrome type I (CRPS I) is a painful neuropathic disorder with an antecedent disproportionate trauma leading to spontaneous pain, hyperalgesia, impaired motor function, swelling, changes in sweating and vascular abnormalities without nerve injury. Whether this syndrome is the result of central or peripheral autonomic dysfunction is still a matter of debate. The purpose of this study was to determine the activity of the sympathetic nervous system in patients with CRPS I by power spectral analysis of heart rate variability. ⋯ Our results support the hypothesis that the pathogenesis of the early stage CRPS I might be related to an increased sympathetic activity. By assessing the autonomic influence on the heart rate variability in CRPS I patients we could also conclude that this disturbance occurs rather at a central level.
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Handchir Mikrochir Plast Chir · Feb 2010
[Complex regional pain syndrome versus chronic regional pain syndrome (Hand-Finger Syndrome)].
Dystrophy is a main factor of CRPS. A large number of patients do not develop dystrophy but, instead, they suffer from pain with limitation in movement, possible paraesthesia and/or swelling. This is then a chronic regional pain syndrome or (shoulder-arm-) hand-finger syndrome. ⋯ These patients can recover quickly when the right diagnosis is made in good time. 2) Limitation of movement due to scar, neuroma, or elongation pain: a) bizarre functional disabilities can develop; b) due to the patient's complaints, one or several operations would finally be performed, which will not lead to an improvement but rather to an aggravation of the pain; c) socially-induced purposeful pain increase, the typical statement of the patient will be: "I can't stand it any longer". Patients who are socially over-burdened, or have psycho-social problems, may experience a decline of performance or a post-traumatic stress disorder. Several patients will be introduced as illustrations for each of the relevant groups.