Acta Pzdiatr Scand 68: 923-924, 1979 CASE REPORT

REFLEX SYMPATHETIC DYSTROPHY IN TWO YOUNG FEMALES G . WETTRELL, T. HALLBOOK and C. HULTQUIST From tlir Depnrtmrnts of Puediatrics and Surgery, Kiirnsjukhuset, Skovde, Sweden

ABSTRACT. Wettrell, G., Hallbook, T. and Hultquist, C. (Departments of Paediatrics and Surgery, Karnsjukhuset, Skovde, Sweden). Reflex sympathetic dystrophy in two young females. Acta Paediatr Scand, 68: 923, 1979.--Reflex sympathetic dystrophy in paediatric patients is a rarely recognized pain syndrome probably of neurovascular origin. The manifestations in two young females consisted of disabling pain and localized hyperesthesia in lower extremities without evident trauma. Sympathetic block followed by active mobilization and, in the patient with atrophic changes, lumbar sympathectomy, resulted in complete recovery. Reflex sympathetic dystrophy should be considered in the differential diagnosis of pain and tenderness in an extremity.

KEY WORDS: Pain, extremity, children

The Reflex Sympathetic Dystrophy syndrome (RSD) is characterized by persistent pain in an extremity. It involves mainly hyperaesthesia but vasomotor symptoms and atrophic changes may arise as well (2,7). The condition is often disabling and seems out of proportion when compared with the negligible trauma. The syndrome has attracted little attention in clinical paediatric practice and can be misdiagnosed, resulting in severe disability (1, 3 , 4, 5 , 6). This paper describes 2 girls with RSD who were successfully treated with sympathetic blocks, in one patient followed by sympathectomy. CASE REPORTS Case I A 14-year-old girl was first seen at the paediatric clinic after having suffered from pain in her right foot for 8 months. The pain had started after a period of intense physical activity and immobilization with plaster and analgetics had been futile. Physical examination revealed continuous pain up to the level of the malleoli and she could not set weight on her foot. There had been some swelling of the toes at first, but now atrophy with hyper-

keratotic skin and brittle nails dominated. She complained of tenderness on the distal plantar surface and even more so localized to a point on the dorsurn of the foot. The circumference of the right calf was 3 cm less than the left. Deep tendon reflexes and peripheral pulses were equal bilaterally. An X-ray of the affected foot showed an aseptic partial necrosis in the head of the third metatarsal bone as well as a generalized and marked osteoporosis. Measurement of blood flow in the right calf by means of strain-gauge occlusion plethysmography showed a slight decrease compared with the left side. The blood pressures measured in the ankles were equal and thermography showed no significant difference between sides. Laboratory results revealed normal sedimentation rate, and serum protein electrophoresis. A lumbar sympathetic block with 0.25 % bupivacaine hydrochloride was performed with prompt but incomplete and temporary relief. Six days later a right lumbar sympathectomy was done and postoperatively the pain disappeared. Thermography showed the right lower leg and foot to be warmer than the left. After 9 days of intense physical therapy she was discharged painfree and within a few months she resumed full physical activity; the X-ray pictures normalized. No recurrence of pain has been noted during 1 $-year follow-up. Case 2

A 9-year-old girl came to the paediatric clinic with a 9month history of pain localized to the right heel. Initially, the pain had been intermittent but after 3 months it became continuous. For a short period there had been a slight swelling of the foot but no cyanosis. For the last

924

G . Wettvell et a/.

6 months she had been unable to put weight on her right heel and had been walking with a limp. Physical examination demonstrated a hyperesthetic circular area with a diameter of 2 cm on the inner side of the right heel. N o swelling, cyanosis or atrophy of the foot were seen. In the lumbosacral region a vascular birth mark was noted. Deep tendon reflexes and perianal sensibility were normal. X-rays of the calcaneus and of lumbo-sacral regions were normal as were thermography, strain-gauge plethysmography and a bone scan of the foot. On the suspicion of RSD a right lumbar block with 0.25 95 bupivacainechloride was performed with prompt and lasting effect. Repeated therrnographies showed a transient marked increase in warmth of the right foot. Within a month after the block the girl was in full physical activity and during a follow-up period of 6 months no pain has recurred.

DISCUSSION Many confusing names (including minor and major causalgia, Sudeck atrophy, and posttraumatic pain syndrome) have been applied to the symptom complex of reflex sympathetic dystrophy (RSD). Today, RSD is the preferred name, and the syndrome is thought to be a neurovascular disorder (2). The symptoms may occur with latency and after a trauma relatively minor in relation to the severity of the manifestations. In some instances the initiating factor is not recognized (1). The pain and hyperesthesia are usually localized to the site of injury. Sometimes the pain progresses proximally without being confined to a peripheral nerve distribution. This confuses the physicians, who suggest a psychiatric component. Severe degrees of the syndrome also seem to occur more frequently in patients with certain personality traits (1, 7). During the early stages, vasomotor disturbances are often manifested by signs of vasodilation. Later, vasospastic symptoms dominate with coldness, pallor or cyanosis. Atrophic changes involving skin and nails

develop insidiously (2) but are seldom seen in paediatric patients (1). The differential diagnosis may include peripheral vascular disorder or peripheral neuritis, osteomyelitis and tenosynovitis. Therapy for RSD should be instituted promptly to improve the possibility of permanent relief. In the early or mild stages, conservative treatment with analgetics, warmth and physical therapy may be of value (1). In the younger age-group, a more active attitude with diagnostic blocks and, in the severe stages, sympathectomy is often preferred (2). Recently, treatment of a child by transcutaneous nerve stimulation has been reported (6). After relief of pain, active exercise is important in the process of rehabilitation. REFERENCES 1. Bernstein, B. B., Singsen, B. H . , Kent, J. T., Kornreich, H . , King, K . , Hicks, R. & Hanson, V.: Reflex neurovascular dystrophy in childhood. J Pediutr, 93: 211, 1978. 2. Bonica, J . J.: Causalgia and other reflex sympathetic dystrophy. Postgrad Med, 53: 143, 1973. 3. Ferrnaglich, D. R.: Reflex sympathetic dystrophy in children. Pediatrics, 60: 881, 1977. 4. Guntheroth, W. G., Chakmakjian, S . , Brena, S. C., Ricketts, H . J . & Wiederhielm, C. A . : Posttraumatic sympathetic dystrophy. A m J Dis Child, 121: 51 1, 1971. 5. Kozin, F., Haughton, V. & Ryan, L.: The reflex sympathetic dystrophy in a child. J Pediatr, 90: 417, 1977. 6. Richlin, D. M., Carron, H., Rowlingson, J . C., Sussman, M. D., Baugher, W. H. & Goldner, R. D.: Reflex sympathetic dystrophy. Successful treatment by transcutaneous nerve stimulation. J Pediatr, 93: 84, 1978. 7. Wirth, F. R. & Rutherford, R. B.: A civilian experience with causalgia. Arch Surg. 100: 633, 1970. Submitted March 3, 1979 Accepted April 9, 1979

(G. W.) Department of Paediatrics Karnsjukhuset S-54101 Skovde Sweden

Reflex sympathetic dystrophy in two young females.

Acta Pzdiatr Scand 68: 923-924, 1979 CASE REPORT REFLEX SYMPATHETIC DYSTROPHY IN TWO YOUNG FEMALES G . WETTRELL, T. HALLBOOK and C. HULTQUIST From tl...
156KB Sizes 0 Downloads 0 Views