An otherwise healthy and functional 35-year-old man had an undisplaced fracture of the right fifth metacarpal neck after a fall. He presented 21 months later with pain, extensive swelling (Panels A and B), and loss of function in his right hand up to the middle third of his upper arm. On physical examination, there was nonpitting edema, hair loss, allodynia, and vasomotor instability, with increased temperature, sweating, and erythema. These changes had developed since the initial fracture and had progressed slowly. Radiologic studies showed that the fracture had healed (Panel C). Computed tomography of the chest showed axillary lymphadenopathy that was consistent with a benign reactive process. The patient received a diagnosis of complex regional pain syndrome type 1 with a superimposed acute cellulitis, for which he received hand therapy and treatment with antibiotic agents, analgesia, and blockade of the right stellate ganglion. Despite these interventions, there was no improvement, and about 2 years after his fall, the patient underwent amputation of his entire right arm. At follow-up 1 year later, the patient was doing well.
Oliver Guttmann, M.B., B.S. Victoria Wykes, M.B., B.S., Ph.D. National Hospital for Neurology and Neurosurgery London WC1N 3BG, United Kingdom v.wykes@gmail.com
