Reflex Sympathetic Dystrophy

Reflex Sympathetic Dystrophy (RSD) involves severe pain, inflexibility, inflammation and discoloration of the hand or leg. Women are more likely to suffer this complex regional pain syndrome or RSD. They experience burning pain, spasms and weakness in the limbs and are unable to move them. It can affect any limb but it is commonly associated with the hand thereby severely restricting shoulder-hand movement.

In the initial stage (Stage 1), there is increased warmth and inflammation accompanied with excessive sweating and pain of that particular part/limb. Stage 2 or dystrophic Stage involves increased swelling, brittle nails and wrinkled appearance of the affected part. During the atrophic stage or Stage 3, there is a dehydrated and pale appearance in the affected limb.

Injuries to the soft tissue, bone or nerves, surgery or other health conditions can trigger this kind of dystrophy. Bone scans and X-rays help in diagnosis. Thermography is also used to check blood flow to the affected limb. This condition must be differentiated from other similar syndromes such as rheumatoid arthritis and scleroderma.

Mild cases of RSD are treated with NSAIDs. As the condition worsens, stronger medication must be supplemented with suitable pain management such as physical therapy. Bisphosphonates, calcitonin, regional nerve blocks and dorsal column stimulation can provide relief.

Nerve Blocks

A nerve block, an anesthetic injection, is used in the management of severe pain. Nerve blocks are not only used to reduce pain and inflammation but also as a pointer for identifying specific source of pain. It involves injection of a local anesthetic to specific nerves. When regional anesthesia is needed for surgery, a nerve block is often used to numb the targeted set of nerves. In surgical cases, a 'nerve catheter' might be placed to continually supply the nerves with numbing medication and prevent severe pain to the patient. Nerve blocks are more effective than IV anesthetics.

Nerve blocks are used in cases of severe pain such as Raynaud's syndrome, chronic abdominal pain, severe back pain and reflex sympathetic dystrophy. This procedure is done with imaging guidance from fluoroscopy, ultrasound or CT. It allows the radiologist to view the needle movement and guide it to the right location. Soon the patient experiences numbness and pain relief. A nerve block works by blocking or reducing the signals sent to the brain. The risks of bleeding, infection, nerve injury and allergic reaction are associated with nerve block injections.

Smiths fracture

In the US, about 17% of the emergency room visits are due to wrist injuries. Injury of the forearm bone near the wrist joint is known as Smith's fracture. Smith's fracture is a fracture of the distal radius occurring about 2.5 cm from the wrist joint. The fracture is the result from a backward fall onto the outstretched hand. It was the orthopedic surgeon Robert William Smith who described this fracture in his book 'A treatise on fractures in the vicinity of joints, and on certain forms of accidents and congenital dislocations' published in 1847. This fracture is named after him. Smith's fracture is often described as a garden-spade deformity.

Hands perform so many tasks that are fundamental and delicate. Therefore even a minor injury to the hand and wrist can have devastating consequences. Smith's fracture is unstable as the ulnar head can be displaced dorsally and therefore requires urgent attention. The hand and the wrist are so dependent on each other. Therefore when an injury occurs, it affects both the hand and wrist. Smith's fracture are classified as:

Type I: Most stable, extra articular transverse distal radial fracture with palmar and proximal displacement.

Type II: Barton type, palmar-lip fracture of the distal radius with dislocation of the carpus
Type III: Unstable, oblique juxta articular fracture of the distal radius and tilted palmar.

• A Smith's fracture is most commonly caused by people falling onto hard surface and breaking their fall with flexed wrists.
  
• Smith's fracture most commonly occurs in older post- menopausal women exhibiting osteoporosis.
  
• Smith's fracture occurs in adolescent boys and girls with joint surface displacement.
  
• Smith's fracture can be considered as a sports injury
  
  Common complications from Smith's fracture:
• Ulnar nerve injury
  
• Carpal tunnel syndrome
  
• Post traumatic radio carpal osteoarthritis with limited range of motion
  
• Heterotopic ossification
  
• Reflex sympathetic dystrophy
  
• Tendon rupture
  
• Nonunion
  
• Radial shortening

Treatment for Smith's fracture depends much upon the severity of the fracture and other factors such as connective tissue injuries, musculoskeletal structure and neuroanatomy, and dislocations involved. If the fracture is not a displaced fracture, then it can be treated simply with a 'cast' alone. Nevertheless, casting needs close watch so as to ensure that the fracture stays in proper position.