Case Studies
Case 14: An ever increasingly painful foot in a young patient
An 18-year-old fractures her left ankle jumping off a horse. The ankle fracture repairs, but soon afterwards she develops pain in her left foot. She has no significant previous medical history and on examination she has an exquisitely sensitive left foot and yells with pain when it is touched. The skin on the foot is shiny and flushed. Neurological examination of the foot is not possible but X-ray of the foot shows focal osteoporosis.
Your Answer:
Correct answer: The most likely diagnosis is one of reflex sympathetic dystrophy, now renamed complex regional pain syndrome. This is likely to be the case given the injury leading on to the exquisitely painful foot with evidence of autonomic dysfunction as seen with the flushed shiny skin and the osteoporosis.
Your Answer:
Correct answer: The cause of this is largely unknown, but is well described in the context of relatively minor injuries, and may have an explanation in the abnormal expression of adrenoreceptors on peripheral nociceptors.
Your Answer:
Correct answer: The treatment of this is often complicated, but emphasis is made on trying to deal with the sympathetic nervous system through local sympathectomies.
Your Answer:
Correct answer: The important thing is to try and treat her symptoms using a range of local measures and painkillers, and she should resist the temptation to have an amputation or some other nerve lesion treatment as a way of trying to deal with her problems as this often greatly aggravates the situation, and can lead to phantom limb pain.