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Condition

Complex Regional Pain Syndrome (CRPS)

A disproportionate, persistent pain response after an injury or surgery. Early recognition and aggressive therapy-based treatment give the best chance of full recovery.

What is CRPS?

Complex regional pain syndrome (CRPS) is a pain condition that can develop after an injury, a fracture, or a surgery on the hand or wrist. The pain is out of proportion to the initial injury — it is more severe, more prolonged, and more widespread than expected — and it is accompanied by changes in the skin, temperature, swelling, and motion of the affected limb. CRPS can happen after something as minor as a wrist sprain or as major as a distal radius fracture surgery, and it can affect anyone.

CRPS used to be called reflex sympathetic dystrophy (RSD) or causalgia. The name was changed because the underlying biology turned out to be more complicated than a simple overactive sympathetic nervous system.

Common symptoms

  • Burning, aching, or stinging pain that is much more severe than the original injury would explain
  • Extreme sensitivity to light touch or to clothing brushing the skin (allodynia)
  • Changes in skin color — the hand may look red, purple, mottled, or pale
  • Changes in skin temperature — the hand often feels warmer or cooler than the other side
  • Swelling that does not follow the usual pattern for a healing injury
  • Changes in sweating — the hand may sweat more or less than the other side
  • Stiffness and reluctance to move the fingers; the patient often holds the hand protected and immobile
  • Changes in hair growth or fingernail appearance over weeks to months
  • Weakness, tremor, or a feeling that the hand does not belong

Why does it happen?

The exact cause of CRPS is not known. It is thought to involve an abnormal response of the nervous system and the inflammatory system after an injury, so that signals that should fade as the tissue heals instead become amplified and persistent. CRPS is not "in the patient's head," and it is not caused by anything the patient did or did not do.

How it is diagnosed

There is no single blood test or imaging study that diagnoses CRPS. The diagnosis is made clinically, using a set of criteria (the Budapest Criteria) that look at the categories of symptoms above. Dr. Barrera will examine the hand, look for the specific pattern of sensory, vasomotor (color/temperature), sudomotor (sweating), and motor changes, and confirm that no other explanation (a missed fracture, nerve injury, infection, or compartment syndrome) is causing the symptoms. A bone scan is sometimes ordered to look for a specific pattern that supports the diagnosis.

Treatment options

The single most important principle in CRPS is that the affected hand must keep moving. Immobilizing a hand with CRPS almost always makes it worse. Treatment is a team effort — often involving a hand surgeon, a certified hand therapist, a pain management specialist, and sometimes a psychologist — and works best when started early.

Hand therapy (the foundation)

  • Active range-of-motion exercises started gently and progressed steadily
  • Desensitization — graded exposure of the hand to different textures so the nervous system learns that light touch is not dangerous
  • Edema control — elevation, retrograde massage, compression garments
  • Mirror therapy and graded motor imagery, which retrain the brain's map of the hand

Medications

  • Nerve-pain medications such as gabapentin or pregabalin
  • Short courses of oral steroids early in the disease
  • Topical medications (lidocaine, compounded creams)
  • Bisphosphonates in selected patients
  • Vitamin C after distal radius fractures appears to reduce the risk of CRPS and may help if already present

Pain management interventions

  • Sympathetic nerve blocks (stellate ganglion block for the upper extremity) — can provide pain relief and allow more aggressive therapy
  • Spinal cord stimulation for refractory cases

Surgery

Surgery is not a treatment for CRPS itself. In fact, operating in a CRPS-affected limb can worsen the condition. However, if there is a specific surgical problem that is contributing to the pain (a trapped nerve that can be released, for example), that operation may be appropriate once the CRPS is under control, usually with the help of pre- and post-operative sympathetic blocks.

What to expect at your visit

Dr. Barrera will carefully review the history and examine the hand to confirm the diagnosis and rule out other causes. He will coordinate a treatment plan with a certified hand therapist and, when indicated, a pain management specialist. The emphasis early on is on motion, desensitization, and getting ahead of the condition before it becomes entrenched.

Dr. Barrera's approach

CRPS is best thought of as a race against time. The longer it goes untreated, the harder it is to reverse. The most important steps are making the diagnosis early, getting the patient into the hands of an experienced hand therapist, and keeping the hand moving — even when it hurts to do so. Dr. Barrera works closely with hand therapy and pain management colleagues to coordinate this kind of multidisciplinary care.

When to call the office sooner

Call us if pain is getting worse rather than better after an injury or surgery, if the hand becomes extremely sensitive to light touch, if you notice persistent color or temperature changes compared to the other hand, or if you are avoiding using the hand because of pain. Early evaluation matters.

Related

Distal radius fracture · Home hand therapy

Questions?

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