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Results
Population and Clinical Criteria
Table 1 and Table 2 summarizes the data. In the study period, 132 patients were admitted with the diagnosis of CRPS of the hand. Of these 132 patients, 16 cases of partial forms of CRPS involving three rays at the maximum were selected. All fulfilled the French criteria. The cases involved 11 men and 5 women with a mean age of 43 years, admitted for 30 days on average. Of these 16 cases, 14 fulfilled all the Budapest clinical diagnostic criteria. With regard to the criteria (see Table 2), 4 symptoms were present in more than 50% of our patients: continuous pain, reduced mobility, hyperaesthesia/allodynia and oedema. Six clinical signs were also present in more than half: reduced mobility, change/asymmetry in colour, trophic disorders, change/asymmetry in sweating, hyperaesthesia/allodynia and oedema. Motor dysfunction was observed in 4 patients: exclusion of the thumb from function with thumb-in-palm (2 cases), thumb in permanent extension (1 case) and permanent reducible passive flexion in 4 and 5 fingers (1 case) (see Figure 1). During the hospitalization, two motor dysfunctions improved and the two others didn't.
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Figure 1.
Clinical aspect:23-year old female patient, contusion of the hand, development of pain and attitude of contracture that was partly reduced in the 4and 5fingers of the left hand.
Radiological Examinations
The data are summarised in Table 2. Standard radiography of both hands in the anteroposterior view was performed on the same film in 14 patients (88%). Radiography showed localised demineralisation of the affected ray(s) in 6 patients (43%). The demineralisation appeared mottled in 2 cases only. TBPS was performed on the 16 patients, but was available for 15 only. It was performed 220 days (median 155 days) on average after the initial accident. TBPS was performed during hospital stay in 87% of cases by the same specialist. In 12 cases (80%), TBPS supported the presence of CRPS. When it was performed before 6 months (53% of cases), six cases of stage 1 and two of stage 2 were found. When TBPS was performed (7 cases) more than 6 months after the trauma, the images did not support CRPS (3 cases) or were consistent with stage 2/3 or 3 (2 cases). In only 2 cases there was a suggestion of stage 1 or 2. In the two patients who did not meet the Budapest criteria for CRPS, TBPS was clearly in favour of CRPS stage 1. The MRI of the hand, performed 4 times, provided no evidence to support CRPS in 3 cases out of 4. In the last case, carpal oedema was associated with synovial thickening causing contrast uptake, 1 month after the accident, compatible with incipient CRPS.
Evaluation of Treatment's Results and Evolution
The pain on a VAS at admission and discharge was available for 14 of the 16 patients (88%). Mean pain on the VAS on admission was 55 mm and on discharge was 43 mm. Seven patients (47%) showed at least 30% improvement compared to the admission VAS (from 59 mm to 29 mm on average). The DASH questionnaire on admission and discharge was available for 12 patients with a mean score of 55/100 on admission and 51/100 on discharge giving a mean reduction of −4 points. Only 3 patients (25%) had an admission/discharge difference greater than 12.75 points. The VAS "patient beneficial treatment effect" was available for 14 patients (mean of 59 mm). In 11 cases (79%) it was greater than 30 mm (from 37 to 100 mm). With regard to professional activity, 4 to 9 years after the hospitalization, 50% of patients hadn't returned to work, but we didn't know the exact reason. 44% returned to the same job or an adapted job. One patient had an invalidity pension because of another injury (severe cranial trauma). The mean compensation duration was 202 days before and 463 days after hospitalization.
Literature Review
Fourteen articles were identified. Half of these were excluded. Two articles presented case series but without details of the clinical findings and thus could not be used in this review; four articles were about CRPS type 2 and the case in the last article was not convincing. Seven articles were finally included involving 19 cases. The comparative sample consists of these articles. The diagnostic criteria used, when given, varied (Doury, Amadio, Veldman) and no study applied the Budapest criteria. The diagnosis of CRPS was assessed on the basis of the clinical and radiological descriptions in the articles. The literature data are summarised in Table 1 and Table 2. Compared to our series, there were more women and 75% of cases were post-traumatic in origin. Mean diagnostic delay was much shorter (2.7 months versus 7.5 months). The main symptoms were pain, hyperaesthesia/allodynia and oedema. The clinical signs present in more than 50% of cases were reduced joint mobility, hyperaesthesia/allodynia and oedema. Standard radiography was performed in 58% of the cases and demonstrated demineralisation of the affected ray(s) in 72% of cases. TBPS was performed in 52% of cases. It was always considered to support the diagnosis of CRPS, but only data from the delayed phase were described. No data on MRI were available.
With regard to evolution, 8 patients (42%) were cured and 6 (31%) improved with an extension of 6 to 12 months. Two patients were in permanent disability at 1.5 and 9 years.
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