Sudeck's disease

Synonyms in a broader sense

• Sudeck's healing derailment
• Algodystrophy
• Causalgia
• Sudeck syndrome
• Post-traumatic dystrophy
• Complex Regional Pain Syndrome
• Complex regional pain syndrome I and II
• Reflex sympathetic dystrophy
• Sudeck's disease

English: Complex Regional Dysfunction System

introduction

At the Sudeck's disease (also CRPS I = C.ronic R.egional Pain S.yndrome) at least one joint is affected.
Usually this is on the hand or foot, but an involvement of the knee, hip or shoulder is also conceivable as part of this disease. Initially the symptoms are relatively unspecific and easy to confuse with those of inflammation. However, the inflammation values ​​in the blood are not increased.

definition

Painful dystrophy (nutritional disorder) and atrophy (shrinkage) of the soft tissues (muscles, skin) and bones of the extremities with a typical stage-like course.

Symptoms

Sudeck's disease can cause many different symptoms. A generalization does not do justice to the complex of symptoms. Laan and Goris, 1997 examined the frequency of individual symptoms (signs of disease).

Inflammation symptoms:

• Pain (burning deep pain) 92%
• different skin temperature 98%
• Movement restriction 90%
• load-related complaints 98%

Atrophy (tissue loss):

• Skin 38%
• Nails 15%
• Muscles 40%

Neurological symptoms:

• Hypesthesia (skin feeling poor) 69%
• Hyperpathy (painful sensitivity to touch) 75%
• Incoordination 53%
• Tremor (shaking) 54%
• involuntary movements 19%
• Muscle spasms (muscle cramps) 11%
• Paresis (paralysis) 98%

Sympathetic symptoms:

• excessive sweating 57%

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causes

Finding the cause of Sudeck's disease is still ongoing. It is a very heterogeneous clinical picture with different degrees of different symptoms. The following things are considered important for the development of the disease:

Impaired regulation of body temperature

The combination of increased sweat secretion and widening of the vessels is a typical function of the central heat regulation. It normally affects the entire body and, under certain conditions, ensures that the body temperature is maintained. The spontaneous one-sided occurrence of this reflex pattern in Sudeck's disease is an expression of a disturbed central thermoregulation.

Sympathetically entertaining pain

Under physiological conditions there is no interaction between the sympathetic and the pain-conducting system. A stimulation of the sympathetic trunk does not lead to any activation of pain-conducting nerve cells. This situation changes under the pathophysiological conditions of the neuropathic Sudeck's disease.

Inflammation

Studies suggest that localized nerve inflammation (neurogenic inflammation) is important in Sudeck pain, acute swelling (edema), and vasodilation (vasodilation).

Central nervesystem

The paralysis (paresis) of almost all muscles in the affected extremity is caused neither by the pain nor by the edema, but in the absence of a peripheral nerve lesion most likely resulted from a reduced activity of central motor neurons. This underlines the important role of the central nervous system (CNS).

Psychological factors

Psychological symptoms (depression, anxiety, somatization tendency, inhibition of aggression and emotional lability) occur more frequently. However, the psychological symptoms are demonstrably the result and not the cause of the disease.

Occur

When does Sudeck's disease occur?

To 50% to

• Contusions (bruises)
• Sprains
• Fractures (broken bones / Broken bone)
• Dislocations (joint dislocations)
• After operations / surgery

to 25% without

• apparent cause

to 20% to

• Neuropathies (nerve disorders)
• Myocardial infarction (heart attack)
• Coronary insufficiency (coronary artery disease)
• Hyperthyroidism (overactive thyroid)

to 5% to

• Medicines (e.g. barbiturates (sleeping pills))

frequency

The preferred age for developing Sudeck's disease is between 40 and 60. Age. With 15,000 cases per year, Sudeck disease is not a very rare disease. Depending on the source, the frequency of occurrence of M. Sudeck after accidents is given as 0.05-5%. Women are affected more often than men. The reason for this is unknown. Children rarely develop this clinical picture.

The hand with the forearm and the foot affected with the lower leg. But the hip, shoulder or elbow can also be affected.

diagnosis

Diagnosing Sudeck's disease is difficult because of the wide variety of symptoms. There is no gold standard. The medical history (anamnesis), the clinical examination and the doctor's experience with the clinical picture are of decisive importance.

roentgen

Side-by-side X-ray examinations should be aimed for. However, the first changes are only detectable weeks after the onset of the disease. Signs of Sudeck's disease are patchy, diffuse bone decalcification. See: X-ray

MRI

MRI examinations of the affected area (MRI of the hand or MRI of the foot) with IV gadolinium administration show increased signals in the soft tissues and bones even in the early phase. The problem with this investigation is the low specificity.

Although Sudeck typical changes can be recognized early (high sensitivity), other clinical pictures can also cause such changes. The MRI must therefore always be seen in the context of all other symptoms; it alone does not prove Sudeck's disease.
Please also read our topic: MRI

Skeletal scintigraphy

The 3-phase skeletal scintigraphy with 99 Tc-diphosphonate shows, with high sensitivity and specificity, an increased periartricular bone remodeling with hyperemia and hyperperfusion as a typical sign. Read more about the method of scinitigraphy under: Scintigraphy

Thermography

The thermography is carried out with an infrared camera. A temperature difference of 1.5 - 2 ° C compared to the healthy side is indicative.

Sudometry

Quantitative Sudometry is used to determine the differences in humidity in a welding chamber.

Differential diagnosis / alternative causes

A number of other diseases can more or less simulate symptoms of Sudeck's disease. This includes the following diseases:

• Fractures / broken bones
• Distortions / contusions (dislocation / contusion)
• Compartment syndrome
• Overuse Syndrome
• Thoracic outlet syndrome e.g. through a neck rib
• Peripheral nerve constriction syndrome (nerve constriction of various causes)
• Lymphatic congestion (edema)
• Myofascial pain syndrome / fibromyalgia (soft tissue rheumatism)
• Phlegmon (inflammation of the tissue) and other bacterial inflammatory diseases
• Insect bite
• Post-traumatic vasospasm (vasoconstriction)
• Raynaud's syndrome and other arterial circulatory disorders
• Thrombosis / thrombophlebitis
• Rheumatic inflammatory diseases e.g. Rheumatoid arthritis

Stages

Staging:

Sudeck's disease is divided into 3 stages.

Stage I (classification criteria):
Acute inflammation, sympathetic dysfunction, usually after 2-8 weeks after the accident

• acute onset (hours / days) after trauma
• inflammatory phase with hyperemia
• edematous swelling
• Spontaneous and stress pain
• Overheated, often shiny skin (reddish / livid)

Symptoms:

• especially pain at rest at night
• Movement and exercise pain
• limited joint mobility
• Excessive sensitivity to touch
• Hyperhidrosis, hypertrichosis, increased nail growth

Stage II (classification criteria) Chronic dystrophy:

• Dystrophy
• Swelling regression
• Pain on the move
• the skin impresses as pale "shiny skin"

Symptoms:

• incipient joint stiffening
• Reduction of resting pain
• palmar / plantar fibrosis
• Soft tissue shrinkage
• pale, cool, shiny skin

Stage III (classification criteria): irreversible atrophy

• Atrophy after about 3 to 12 months
• Malfunction
• Contractures
• atrophic, dry wax skin

Symptoms:

• decreasing pain
• advanced joint stiffening
• Muscular atrophy
• Reduced strength
• so-called "weather sensitivity" of the complaints

cure

Important for the Treatment of Sudeck's disease is above all an early and stage-appropriate, multimodal therapy.
For a cure, the detection of this clinical picture as early as possible is particularly important.
The best chance of recovery is when there is no nerve injury.

In a few cases, this disease can be completely cured, but mostly only in close cooperation with specialized doctors and teams of experts in this field.
It is important here that the practitioners are well versed in the therapy of Sudeck's disease and, if necessary, work on an interdisciplinary basis.

Teams of experts therefore often expose themselves Orthopedists, Pain therapists, Physiotherapists, Energy therapists and Psychotherapists together. Often a certain pain symptoms persist or the disease recurs at irregular intervals. For these patients, it is of great importance to be cared for closely by the teams of experts already mentioned, in order to allow them at least some control of the symptoms.
This usually succeeds. Only a small group of patients is permanently particularly badly affected by this disease.

In the case of those affected, the agonizing pain symptoms usually persist and they have to complain about functional restrictions of the affected extremity.
But even if the pain cannot be completely treated, it is important that those affected also seek psychological help at an early stage, as chronic pain can often lead to further psychological illnesses. These can then in turn worsen the symptoms and thus lead the person affected into a vicious circle.
It therefore makes sense to start psychotherapy or behavioral therapy in addition to pain therapy in order to be able to combat or even prevent further problems at an early stage and to contribute to an overall improved quality of life.

Read more on the topic: Healing of Sudeck's disease

forecast

88% (Maier C. 1996) were symptom-free after rapid confirmation of the diagnosis and multimodal therapy (temporal application of various forms of therapy). Monotherapies (individual therapy) gave significantly worse results.

2% recurrence rate (recurrence after healing) whereby the opposite side can also be affected in approx. 50%!

Spontaneous remissions (disappearance of the disease without therapy) with full symptoms are rare.

A small percentage is resistant (inability to therapy) to any known form of therapy.

Localization of Sudeck's disease

Sudeck's disease on the hand

One can hold a Forearm fracture (distal radius fracture) lead to the development of Sudeck's disease. This is also the most common cause and occurs in around 7 to 37% of cases with this type of fracture.
Other fractures in the arm area can also lead to Sudeck's disease of the hand in 1 to 2%, and nerve injuries are also considered to be a possible trigger.

Affected patients usually complain of severe symptoms in the early phase of the disease Pain in the hand, Redness, swelling, overheating and pain when moving the joint with an associated functional impairment. This first phase lasts about a month.
The most specific symptom for Sudeck's disease is the long-lasting pain. This can have different characters. Often it is a sharp pain. But there can also be an unpleasant tingling sensation or even permanent burning, for example in the affected hand.
The pain occurs even at rest, but can be aggravated by slight movements or the application of pressure.

In addition to the pain symptoms, other symptoms usually occur. For example, increased fluid accumulation in the tissue often leads to a Swelling of the affected hand. In addition, reddening and an increase in temperature compared to the opposite side can occur over the course of the treatment. This can be done on a Circulatory disorder in the arm which can then also be identified by the external appearance of the affected region. The hand often looks paler than the other and due to the additional swelling it often has a wax-like appearance. In the chronic course, the affected hand may feel increasingly cold and even take on a bluish skin tone. The reason for this is a chronic reduced blood flow in this area.

Other symptoms can include increased sweating or tremors. Those affected often observe an initially accelerated growth of hair and nails on the diseased extremity, which in the further course turns into the opposite.

The problem most distressing for patients associated with this disease is the increasing problem Restriction of movement.
Since Sudeck's disease is a dysregulation of the nerves, not only is the skin and blood flow affected, but bones and muscles can also be affected.
If these are no longer properly controlled and supplied over a longer period of time, they may also recede. The result of this is usually a stiffening of the joints, which consequently restricts the range of motion of the entire hand and, in the worst case, ends in the complete stiffening of the affected extremity.

Sudeck's disease on the foot

Involvement of the upper extremity Sudeck's disease While it is slightly more common, it is also possible that other joints, such as the ankles, are affected.

Here, too, the focus is initially on permanent pain in connection with an increased sensitivity to pain.
These can last for several months.
Then there are also other symptoms, such as swelling, which can be explained by increased fluid accumulation in the tissue.

A strong reddening and an increased temperature in the side comparison can also be observed in the context of the swelling. Since the skin is stretched by the swelling, it may appear waxy as a result.
It can also be through the Circulatory disorder in the legs There is a change in skin color and temperature over the affected area.

In the chronic phase, the affected foot usually turns bluish and there is an increased feeling of cold for the affected part of the body. Increased sweating or even tremors can occur.
Accelerated growth of the toenails in the initial phase may also be observed on the foot.

In the further course of the disease, however, this changes to the opposite and there are usually functional restrictions and loss of mobility of the affected joint.
Both the muscles and the bones can be affected, which can lead to stiffening of the affected joints. This is particularly important for the ankles, as these are crucial for everyday movement. If the foot stiffens, this can be associated with walking difficulties and may make a walking aid necessary.

Sudeck's disease on the knee

The clinical picture of Sudeck's disease mostly affects hands and Feet.
In some cases, involvement of the knee joint may also be possible. Here, too, the focus is initially on pain, but swelling with red and overheated skin over the knee joint can also occur.

Increased sweating and accelerated hair growth is also conceivable. In the further course, however, there is usually a rather pale to bluish skin discoloration and a slight decrease in temperature compared to the opposite side. In the chronic stage, there is often a functional impairment with stiffening of the knee joint.
This in turn can lead to walking difficulties.