P056: AN ATYPICAL CASE OF CRPS WITH ARTHROFIBROSIS TREATED WITH REGIONAL CATHETER PLACEMENT
Dennis J Warfield Jr, MD, Peter Murray, MD, Michael Osborne, MD, Steven Clendenen, MD; Mayo Clinic
Introduction/Background: A 39-year-old female sustained a right open distal radius fracture after a motor vehicle accident. She emergently underwent irrigation, debridement and open reduction and internal fixation of her distal radius fracture and placed in a mid-humerus cast for six weeks. With discontinuation of the cast, she was started on a progressive physical therapy regimen, but found to have limited progress due to decreased range of motion (ROM) in the right upper extremity, with the primary deficit being her right elbow. Over the course of three months the patient exhibited signs and symptoms of numbness and tingling within her right median nerve distribution along with color and temperature changes in the hand. The patient was furthermore referred to pain management for treatment of her suspected CRPS Type 2 with optimization of her overall limited ROM.
Methods: A peripheral nerve block catheter was placed by our regional anesthesiology and acute pain service for dual purpose. The goals were to provide prolonged nerve block for a break in cycle for pain control with potential RSD treatment while simultaneously helping to facilitate aggressive physical therapy manipulation for increase ROM treatment. A continuous interscalene peripheral nerve block catheter was completed with a total of 19ml of 0.5% Ropivacaine. An additional supraclavicular single injection peripheral nerve block was completed with a total of 10ml of 0.5% Ropivacaine for completion of surgical blockade. The interscalene catheter was attached to a high flow infusion system (On-Q*, Alpharetta, Georgia) with 0.2% Ropivacaine at 5 ml per hour for a total of five days. Complete surgical anesthesia of the right ulna, radial and medial nerve distribution was achieved to enable the initial manipulation of her right upper extremity. The patient reported no pain with passive flexion and extension of her extremity. The patient later underwent inpatient physical therapy over the course of the next three days for further rehabilitation.
Results: Upon orthopedic surgery follow-up, just under two months later, the patient had remarkable improvement. The paresthesia previously noted in her right hand had subsided and ROM especially in her right elbow greatly improved. The patient was ultimately released to activity as tolerated with further concentration on her focused therapy regimen. She was very happy with her progress, ultimately able to regain function to complete activities of daily living.
Discussion/Conclusion: What we portray in this case report is an atypical case of Complex Regional Pain Syndrome type 2 with concomitant arthrofibrosis. The mainstay of this approach is the substitution of treatment with a continuous interscalene peripheral nerve block catheter versus conventional treatment with stellate ganglion sympathetic blockade. Our approach allows for prolonged complete anesthesia permitting more aggressive initial passive physical therapy in the early stages for treatment and optimization of limited range of motion. We show that this commonly performed technique for peripheral nerve blockade in the acute perioperative setting can be used in conjunction with pain management treatment and physical therapy on an outpatient basis as a different method assisting in accomplishing aggressive rehabilitation.