CHANGES IN CORTICAL AND TRABECULAR BONE IN ALGODYSTROPHY

We studied the pattern of bone loss in the hand of 77 patientswith Colles' fracture using metacarpal morphometry, single photonabsorptiometry and a radiographic scoring system. Forty-fourpatients had post-traumatic algodystrophy and the remainderserved as controls. Both groups were immobilized in the samemanner and for the same period of time and both showed lossof bone during immobilization. The loss of bone 7 weeks afterfracture was significantly greater in algodystrophy than incontrols both at cortical (P<0.05) and at trabecular sites(P<0.05). Recovery of bone occurred in the control patientsby 19 weeks after fracture at cortical sites and by 31 weeksin trabecular bone. In contrast, the bone loss seen in patientswith algodystrophy persisted for the 6-month duration of thefollow-up, and up to 1 year in all nine patients studied forlonger. These findings indicate that post-traumatic algodystrophyis associated with regional skeletal losses greater than thosefollowing uncomplicated fracture and may result in irreversiblechanges in the structure and thus the strength of the bony architecture. KEY WORDS: Colles' fracture, Bone density, Photon absorptiometry, Metacarpal morphometry, Immobilization, Reflex sympathetic dystrophy     

THE USE OF NASAL CALCITONIN IN THE TREATMENT OF POST-TRAUMATIC ALGODYSTROPHY

Calcitonin is widely used in the treatment of algodystrophybut a major disadvantage is the need for its parenteral administration.For this reason, we evaluated the effect of 400 iu of nasalcalcitonin in the treatment of post-traumatic algodystrophyin a prospective randomized double-blind study. We found nodemonstrable effect on the clinical or skeletal progressionof the disorder using sensitive methods of measuring the responseto treatment. There was, however, a small but significant hypocalcaemicresponse in the treatment group despite no change in the otherindices of bone turnover. Possible reasons for this lack ofclinical and skeletal effect are discussed. KEY WORDS: Colles' fracture, Reflex sympathetic dystrophy, Bone density, Serum calcium     

QUANTITATIVE BONE SCINTIGRAPHY IN REFLEX SYMPATHETIC DYSTROPHY

We have investigated the appearances of the technetium-99m labelledmethylene diphosphonate bone scan in 29 scans performed in 16patients with post-fracture reflex sympathetic dystrophy (RSD)of the hand. There was a close correlation between increaseduptake in the metacarpophalangeal joints and the metacarpalbones, suggesting that the increased uptake in RSD is not confinedto the periarticular areas as has been previously reported butoccurs throughout the affected region. In seven cases examined3 months after fracture, RSD was associated with a significantincrease in uptake at all sites in the hand on the delayed scanwhich was not seen in matched post-fracture controls, confirmingthat increased uptake on delayed bone scintography is a sensitivetest for the presence of RSD even in the presence of a fractureof the wrist. The early increased uptake gradually returnedto normal. Local tenderness assessed by dolorimetry was correlatedwith increased uptake, suggesting that the bone scan is notonly useful as a diagnostic tool but also provides a quantitativeindication of the severity of the condition which may be usefulin planning and assessing treatments. KEY WORDS: Reflex sympathetic dystrophy, RSD, Algodystrophy, Südeck's atrophy, Bone scintigraphy     

ALGODYSTROPHY: AN UNDER-RECOGNIZED COMPLICATION OF MINOR TRAUMA

Algodystrophy is a poorly recognized condition of uncertainaetiology which presents with pain and tenderness, vascularinstability, swelling and stiffness of an affected limb. Itis most commonly seen after trauma. In order to ascertain itsincidence, natural history and the degree of morbidity inducedwe studied prospectively 274 patients with Colles' fracture.Algodystrophy, as judged by the presence of bone pain or tenderness,vasomotor symptoms, swelling and stiffness of the hand was notedin 28% of patients. There was a significant association betweenthe presence of these features (P<0.0001). The degree oftrauma sustained was identified as a predisposing factor. Actuarialanalysis showed a gradual resolution of symptoms. Six monthsafter injury, the proportion of patients complaining of painand swelling had fallen to 20–30% vascular instabilityand tenderness to 50% and stiffness to 80%. Failure to improvewas associated with a significant loss of hand function (P<0.0001).By 1 yr, pain and tenderness, vascular instability and swellinghad decreased still further but stiffness was still apparentin 50%. We believe that algodystrophy is a neglected disorderand is far more common than formerly appreciated. Although itoften resolves spontaneously, it is associated with a significantincrease in short-term morbidity in the majority of patientsand persistent dysfunction in a minority. KEY WORDS: Algodystrophy, Reflex sympathetic dystrophy, Natural history, Trauma, Colles fracture