Confidentiality

‘Model Discussion’ available

 Orthopaedic referral  Thankyou for seeing this 9 yo girl for assessment and management of suspected RSD left leg following fractured cuneiform. Her GP is aware.

 ED: She fell off fence 9 wks ago   twist and fell whilst in plaster  # cuneiform more pain and swelling  split  reapplied plaster 4

 ED: She fell off fence 9 wks ago   twist and fell whilst in plaster  # cuneiform more pain and swelling  split  reapplied plaster  Fracture Clinic: Pain, purple colour, swelling and limited movement persisted after removal of plaster  non-wt-bearing using crutches, paracetamol or ibuprofen, awaiting physio 5

An aside on ‘RSD’

Short for Reflex Sympathetic Dystrophy Now called Complex Regional Pain Syndrome (CRPS) A clinical pain syndrome     Following (usually) an injury Spontaneous pain, hyperalgesia*, allodynia* in a region Accompanied by vascular, swelling, sweating and motor changes Other causes excluded 7

The opening minute

Pause

 What feelings does this child/family create in you?

 How can we manage ourselves?

 How can we manage this child/her family?

Peter Anne ‘Tweens’ Shane Kylie Topaz 1 ½yo Teora 9yo 20yo 10

Nan – Anne

 1994 #5 th metatarsal  CRPS diagnosed  CRPS ‘went through all 4 limbs / whole body’  GP and pain service  ‘went through all the drugs and side-effects’  Guanethidine blocks, physio, hydro,  Wheel-chair for 10 yrs, considered amputation  Pain program, ‘threw away the drugs’ got back to walking, still ‘suffers terribly’ but ‘gets on with it’  Migraine, wrestless legs, burning soles, heat/cold intolerance, hypertension 11

Mother – Kylie

 1995 MVA #femur, #ribs, back pain and PTSD    2000 post-natal depression 2002 #wrist  CRPS diagnosed GP, hand surgeon, 2 pain services  Multiple interventions/meds, considered amputation  Opioid dependent, awaiting wrist fusion surgery  Migraine, wrestless legs, heat/cold intolerance, hypertension, depression, ?other mental health, ?D&A problems 12

Child – Teora

    Born 36/40 gestation, CPAP, reflux Mild asthma 3 yrs ago # forearm 2yrs ago scooter fall (no helmet) CHI / L knee pain  persistent somatic knee pain, normal imaging  9wks ago jump from fence # L foot bone  persistent ankle and foot pain  5wks ago traction injury left wrist no # evident  persistent wrist and hand pain 13

Child – Teora

Teora’s Pain

     Lateral heel/hindfoot Horrible, aching Range 8-10/10 (Faces-R) ↑ Touch, weight, movt, ‘fights’ ↓ Nothing (simple Rx, codeine)

Teora’s Foot

(not) 16

Teora’s Foot

(not)          Tubigrip Partial wt-bearing on 1 crutch Redder, mottled Mild swelling Dry skin Cool to ankle Reduced touch, pain, cold over lateral hindfoot, malleolus, heel Allodynia and hyperalgesia over remainder to distal 1/3 calf Flicker of ankle and toe movt 17

Teora’s Life

 Sleep disturbed, sleeping with Nan  Unable to wear sock or shoe  Mobilising on one Canadian crutch  Begging for 2 crutches (‘you had a wheelchair!’)  Attending school but feeling doubted / isolated  Missing leisure and social interactions  Angry, distressed  Wanting to cut leg off 20

Teora’s Thoughts and Emotions

Pause

Another aside on CRPS

1 symptom in all 4 categories + 1 sign in 2 categories = CRPS 24

Adult v Childhood CRPS

Berde 2005 25

Genetics?

What we know…

   On a population level, genes don’t count for much CRPS CRPS can occur in families, but mode of inheritance unclear Those with familial CRPS are more likely to: – – – Develop it younger Have multiple affected extremities Have associated dystonia    Genes that show no association – SCN9A, NEP, DYT HLA complex implicated – HLA-B26, HLA-DQ8 CRPS-1 in childhood associated with maternally inherited mitochondrial disease 27

Family System?

Teora’s Progress

    Information for child and family Paediatric physio + CAMHS + trial of antineuropathic Rx Over next 2-3 months her pain improves Teora returned to school, handball 29

Teora’s Progress

    Information for child and family Paediatric physio + CAMHS + trial of antineuropathic Rx Over next 2-3 months her pain improves Teora returned to school, handball     BUT  Growing number of somatic complaints Starts going to sick-bay daily Defiance and behavioural challenges Anxiety and nightmares Additional injuries 30

Teora’s Injuries

     Fall on jetty  L wrist becomes worst pain (not CRPS) Increasing worries about own L wrist pain and her Mother whose left wrist has gone back into plaster  Function stable but somatic complaints and distress increasing Not able to engage in outpatient care plan * Semi-urgent admission planned In meantime...fall on uncle’s boat  distal radius  brace undisplaced # 31

Child Protection