Page 262 Guide to Pain Management in Low-Resource Settings

250 Andreas Schwarzer and Christoph Maier

joint involvement, etc.). Current attempts explain sin- radius was diagnosed in the hospital. Everything seemed
ne after the fracture was treated by osteosynthesis and figle symptoms, but not the overall picture. An essential
hypothesis about the main pathomechanism for de- cast, but within a few days after discharge she felt an in-
ammatory processes. Th is creasing constant burning pain in her forearm, and her flveloping CRPS includes in
ngers got swollen. When visiting her surgeon, she com- fipoint of view is supported by the fact that the classic
ammatory signs (edema, redness, hyperthermia, plained about the pain, and the cast was removed. flin
and impaired function) are prominent, especially in the
early stages of the disease, and that these symptoms are Are the symptoms a “normal”
uenced by the use of corticosteroids. consequence of her fracture? flpositively in
After the application of a looser cast and the prescription
What is the prognosis of patients of pain medication, the pain was tolerable, even though
ngers remained swollen. Six weeks later, the cast was fiwho have developed CRPS? her
removed, and physiotherapy commenced. A few days lat-
Th e number of favorable cases that heal up spontane- er, Etta reported an increase in swelling after the removal
ously or following adequate treatment (and avoidance of the cast and said she felt a stinging, partly burning pain
ngers. Fur- fiof mistreatment), are unknown. Prognosis regarding the circularly around the wrist, radiating to the
ngers was reduced; the fiected limb is unfavor- thermore, the movement of her fffull recovery of function of the a
able, and only 25–30% of all patients fully recover, ac- hand was shiny, swollen, and blueish-reddish.
cording to the degree of severity and their comorbidity.
ects of osteoporotic changes on the Once again, is this a “normal” ffTh e extent of the e
prognosis is still unclear. Th e following symptoms point consequence of her fracture?
to an unfavorable course of the disease: a tendency to Dr. Jones, the attending physician, recommended inten-
joints, contracture in the early stages, pronounced sifying the physical treatment and increasing the doses ffsti
cation of physi- fimotor symptoms (dystonia, tremor, and spasticity), ede- of the pain medication. During intensi
ngers were trained forcefully, which fima, and psychological comorbidity. cal therapy, Etta’s
was very painful. With exercise, the pain and swelling
Which treatment strategies play an increased, and the hand was still bluish-reddish colored
important role in the management and shiny. Moreover, Etta noticed an increased growth
nger nails and the hair on the dorsum of her left fiof her
of CRPS?
ed, the lack fihand. Although physical therapy was intensi
ngers worsened, the hand was con- fiTreatment should take place in three steps: in the begin- of mobility of the
ning, treatment of pain at rest and treatment of edema stantly swollen, and the pain was burning and almost
have utmost priority. Next to pharmacological treat- unbearable, at rest as well as during movement. Etta be-
ment, rest and immobilization are most important. In came desperate, and Dr. Jones was at the limit of his wis-
the second stage, the therapy should include treatment dom on how to help her.
of the pain during movement as well as during physi-
What should be done?
cal and occupational therapy. Pain treatment takes a
Why has Dr. Jones’ therapy failed?
back seat in the third stage, when the emphasis is on
the treatment of functional orthopedic disorders as well Six weeks passed, and Dr. Jones referred Etta to a pain
cation of management center. She was still complaining about fias on psychosocial reintegration. Th e intensi
physical therapy can be limited due to reoccurrence of the pain, which at that point was radiating to the fore-
pain or edema. Th e main rule is that the treatment must arm and elbow as well. Additionally, she reported strong
cits in the hand (it was not possible to finot cause any pain. functional de
nger-palm distance was 10 cm). fist, and the fimake a
Case report In the past few days, she had also noticed a restriction
in the shoulder movements (especially abduction). Dr.
ce worker, had bad luck when Ndungu, the attending doctor from the pain center, rec- ffiEtta, a 58-year-old o
she left her house on a rainy day and fell on the slip- ognized the problem and recommended an appropriate
pery steps of her front porch. A fracture of the left distal treatment; Etta was lucky.