Case Diagnosis: Complex Regional Pain Syndrome Type 2
Case Description or Program Description: A 66 year-old male was admitted to inpatient rehabilitation after a motor vehicle accident for deficits related to right acetabular/femoral head fracture with posterior dislocation, status post open reduction and internal fixation. Upon arrival patient demonstrated impaired dorsiflexion of the foot with intact eversion and grossly intact sensation most consistent with deep fibular nerve injury. During his hospitalization, he developed painful burning sensations in the right foot consistent with neuropathic pain and was managed with gabapentin 300 mg three times daily with modest improvement at discharge. At outpatient follow-up, he complained of worsening pain and was found to have significant right foot erythema, edema, trophic changes, vasomotor symptoms, allodynia, and worsening strength.
Setting: Inpatient and Outpatient Rehabilitation
Assessment/Results: Duplex ultrasound of the right lower extremity showed deep vein thrombosis (DVT), and he was started on anticoagulation and referred to vascular surgery. Arterial and venous studies were normal, and at physiatry follow-up, physical exam revealed severe allodynia, erythema, vasomotor changes, trophic changes in foot, and hidrosis asymmetry -- fulfilling the Budapest Criteria in support of a diagnosis of type 2 complex regional pain syndrome (CPRS). Desensitization therapy was initiated and gabapentin was titrated to 600 mg three times daily with symptomatic improvement.
Discussion (relevance): Peripheral nerve injury recovery is often complicated by neuropathic pain. CRPS has been reported to occur in up to 7% of cases after limb injury; diagnosis is confirmed using the Budapest Criteria. While a DVT can result in lower extremity pain, edema, and erythema especially in the setting of trauma and surgery, it does not typically result in trophic changes or vasomotor symptoms. If such symptoms are present, the clinician should consider the Budapest Criteria and retain a high of suspicion for CRPS.
Conclusions: DVT can present similarly to CRPS and could lead to a missed or delayed diagnosis. A thorough history and physical exam, as well as appropriate consideration of the Budapest Criteria, is necessary in diagnosing CRPS.