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What is the diagnosis?

Complex Regional Pain Syndrome - 1

• Pearl: CRPS-1 is most commonly associated with an inciting event such as a fracture, crush injury, or surgery and is also associated with immobilization.

What is the underlying mechanism?

The underlying mechanism is not well understood; however, in acute CRPS, cytokine levels are upregulated as well as the neuropeptides bradykinin and substance P. It is thought that there is sensitization of both peripheral nociceptors as well as central sensitization leading to pain hypersensitivity. Some level of autonomic nervous system dysregulation is postulated to account for the vasomotor abnormalities frequently seen [1,2].

What physical exam findings are expected?

Examination of the affected region may show hyperalgesia, allodynia, temperature asymmetry, skin color changes, edema, hair changes, sweating, decreased range of motion, weakness or tremor . Diagnostically it should have at least 2 components (sensory, vasomotor, edema, motor) on examination and a report of symptoms in at least 3 of those categories per the Budapest Criteria [2].

Which diagnostic tests should be used?

There is no specific imaging, or laboratory workup that is diagnostic for CRPS [1].

What is the management in the ED?

These patients require rule-out for other urgent causes of their presenting symptoms such as doppler ultrasound for DVT, Xray or CT for fracture or dislocation and evaluation for compartment syndrome. First line treatments for CRPS are regular doses of NSAIDs and/or acetaminophen to improve, but not eliminate symptoms [2,3].

• Pearl: Second-line medications include gabepentinoids, TCA’s, and SNRI’s with variable evidence for their benefit. Early mobilization and rehabilitation is the key to prevention and return of function [2].

When do you consult Orthopedics?

An array of physicians can manage CRPS, specifically their Primary Care Physician, consulting Orthopedic Surgeon, Non-Operative Sports Physician, and PMR. Early referral to Occupational Therapy or Physical Therapy is suggested [2].