Name:
Harrison's Podclass - Episode 87- A 28-Year-Old with Hand Pain and Redness
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Harrison's Podclass - Episode 87- A 28-Year-Old with Hand Pain and Redness
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T00H06M30S
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Upload Date:
2022-06-12T00:00:00.0000000
Transcript:
Language: EN.
Segment:0 .
[upbeat intro music] [Dr. Handy] Hi, welcome to Harrison's PodClass, where we discuss important concepts in internal medicine. I'm Cathy Handy. [Dr. Wiener] And I'm Charlie Wiener and we're coming to you from the Johns Hopkins School of Medicine. [Dr. Handy] Welcome back, everybody to today's PodClass. The episode today is a 28-year-old with hand pain and redness.
[Dr. Wiener] Okay, Cathy, so today a 28-year-old woman comes to see you for pain, redness, and swelling in her right hand. [Dr. Handy] Okay, we need lots more history here, including the timing. If she fell this morning, this could be relatively easy. [Dr. Wiener] Well, I'm glad you mentioned the fall, because that's where her story begins three months ago. She fell while running and she landed on her right hand.
It was immediately painful, so she went to the emergency department where a radiograph showed no fracture. She was given a splint that she wore for a few days. However, since then she's had continued pain and redness in her right hand. The pain was initially localized over her medial wrist, but now it's more diffuse and is involving the entire hand. It's present at rest and it's worse with movement like writing or typing.
And now over the last few days, she's developed forearm burning and edema. She also notes that she's having decreased mobility of her shoulder even. She tells you that despite being athletic her entire life, she's never had symptoms like this after a fall or even minor trauma. She works as the marketing director of a company that makes chocolate-covered strawberries and has no past medical history.
She's not sexually active, she takes no medications, and she does not use tobacco, alcohol or illicit drugs. [Dr. Handy] All right, so it sounds like she had an injury previously and now three months later, for no apparent other reason, things are getting worse. What about the rest of her physical examination? [Dr. Wiener] Well, she's afebrile and her vital signs are normal, her total exam is entirely normal except for her right upper extremity.
So you find that her hand is diffusely red, and there's non-pitting edema to the forearm. Her range of motion is limited at her right shoulder and wrist, in fact, she's unable to raise her arm above the level of her head or even close her right hand. She also reports allodynia to touch over the back of the hand extending up to the wrist and in the forearm.
[Dr. Handy] Did she get any labs or additional radiographs? [Dr. Wiener] Yes, she did get labs. Her white blood cell count is normal. Her AMA and the rest of her rheumatologic panel is negative. X-rays of the shoulder and hand show no fractures. So the question is going to ask, which of the following is the most likely diagnosis? And the options are, A. acute gonococcal arthritis; B. carpal tunnel syndrome; C. complex regional pain syndrome; D. gout; or E. systemic lupus erythematosus or SLE.
[Dr. Handy] Based on the information that you gave, I would say that the answer is C. that the patient has complex regional pain syndrome or CRPS. [Dr. Wiener] What is that? [Dr. Handy] Patients with peripheral nerve injury occasionally will develop spontaneous pain in the region innervated by that nerve. This pain is often described as having a burning quality. The pain typically begins after a delay of hours to days or even weeks and is accompanied by swelling of the extremity, which we hear the patient has.
Damaged primary afferent nociceptors acquire adrenergic sensitivity and can be activated by stimulation of the sympathetic outflow. Now this constellation of spontaneous pain and signs of sympathetic dysfunction following injury has been termed complex regional pain syndrome or CRPS. [Dr. Wiener] What's the pathophysiology? This sounds kind of weird.
[Dr. Handy] The pathophysiology is poorly understood. The pain and the signs of inflammation when acute can be rapidly relieved however by blocking the sympathetic nervous system. This implies that sympathetic activity can activate undamaged nociceptors when inflammation is present and initiate the syndrome. [Dr. Wiener] What are the typical causes of CRPS? Is she typical?
[Dr. Handy] When this occurs after an identifiable nerve injury as is likely in this case with her fall, it's termed CRPS type II. It's also known as post-traumatic neuralgia or if severe, causalgia. When a similar clinical picture appears without obvious nerve injury, it is termed CRPS type I, which is also known as reflex sympathetic dystrophy. CRPS can be produced by a variety of injuries either localized such as from soft tissue trauma or bone fracture.
It's also been described in harder-to-understand situations such as myocardial infarction and stroke. Signs of sympathetic hyperactivity should be sought in patients with post-traumatic pain and inflammation and no other obvious explanation. [Dr. Wiener] How would you treat this? [Dr. Handy] Well, I should first say that if untreated, it may extend to developing periarticular bone loss and arthritic changes in the distal joints.
The pain may be relieved by a local anesthetic block of the sympathetic innervation to the affected extremity. CRPS type I typically resolves with symptomatic treatment, however, when it persists, detailed examination often reveals evidence of a peripheral nerve injury. For both types, physical therapy is often tremendously valuable particularly at a center that specializes in this type of syndrome.
[Dr. Wiener] Okay, so you immediately jumped to CRPS for this woman, what led you away from the other options? [Dr. Handy] Well, acute gonococcal arthritis and gout will have a focal joint fluid collection and inflammation, which we don't see here. Also, this patient said she was not sexually active, making acute gonococcal disease less likely. Systemic lupus can manifest in cryptic joint findings, but in this case, the focality and absence of systemic findings or serologic abnormalities make it less likely.
Carpal tunnel syndrome caused by injury to the median nerve is not consistent with this presentation of pain in the entire arm and shoulder. [Dr. Wiener] Okay, great. So the teaching points in this case are that complex regional pain syndrome or CRPS may arise after a discrete injury or after another sympathetic event, but in any case, it's characterized by a chronic syndrome of sympathetic hyperactivity, pain, and loss of function.
If left undiagnosed and untreated, it may progress to overt arthritis. Treatment is typically local with targeting the specific sympathetic location along with specialized physical therapy. [Dr. Handy] And you could read more about this in Harrison's chapter on disorders of the autonomic nervous system. [upbeat outro music] [Mr. Shanahan] This is Jim Shanahan, publisher at McGraw Hill.
Harrison's PodClass is brought to you by McGraw Hill's AccessMedicine, the online medical resource that delivers the latest trusted content from the best minds in medicine. Go to accessmedicine.com to learn more.