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Stretching exercises are an important part of recovery after sustaining a fracture of the distal radius. However, from the patient's perspective, painful stretching exercises can be counterintuitive after injury. Stretching exercises are straightforward and do not require a significant amount of coaching. It is ultimately the protectiveness, passivity, and sometimes a sense of futility that require coaching. The key for the provider is to empathize with the difficult and counterintuitive nature of the recovery process., (Copyright © 2012 Elsevier Inc. All rights reserved.)

Using a single, simple goniometer measuring the range of joint movement at each joint in the hand, the author has developed a simple method of assessing joint stiffness and algodystrophy. This not only involves testing all joints in the fingers but also is a simple technique that can be performed in the outpatient clinic. Arthrography has been used to measure resistance of passive motion of joints, finding that stiffness is worse in the morning and improves after physiotherapy and after injection with steroids. The author's method does not actively measure the resistance to passive motion in a joint, as does the arthrograph. As the patient recovers with time, however (see Fig. 2), the range of movement increases and this may be equivalent to the improvement seen in Bramley et al. Goniometry has been found to be a sensitive test for diagnosing algodystrophy. Together with dolorimetry, however, the specificity of the two tests combined increases significantly while maintaining adequate sensitivity to use as a diagnostic tool. Consequently, it is possible to diagnose algodystrophy at 1 week following Colles' fracture. This finding has important implications in that it probably means the initial injury is responsible for the disease causation rather than anything constitutional or psychological.

A scoring classification for assessment of the clinical severity of reflex sympathetic dystrophy (RSD) and rating the presence and clinical expression of each feature is proposed. The following were included: pain, reduction of finger flexion, swelling, temperature changes, discoloration, sensory disturbances, shoulder pain and loss of movement, increased sweating, and hair/nail growth changes. For most of these features one point was assigned for strong expression, half a point for moderate expression, and zero points if the feature was absent. A score of four points was assumed, empirically, to indicate a minimal degree of RSD, and the maximum score of 10.5 to indicate fully symptomatic condition. One hundred forty-six patients with RSD of the hand were classified according to those criteria. Seventy-four patients (51%) had a score of 4-6, 51 patients (35%) of 6.5-8, and 21 patients (14%) of 8.5-10. This classification was then used to investigate the influence of clinical severity of RSD on the intensity of uptake of the tracer in three-phase bone scintigraphy. No correlation between RSD score values and intensity of fixation of the radionuclide was found.

Algodystrophy describes a group of extremely polymorphic pathological manifestations caused by vasomotor disturbances. Clinical expressions of algodystrophy are summarized, and principles of treatment are discussed.

Reflex sympathetic dystrophy (RSD) is a syndrome affecting an extremity after a minor trauma or operation. Currently, there is no consensus about the pathogenesis of RSD. The authors performed various clinical and experimental investigations, including studies of the effects of anti-inflammatory treatment, that support the hypothesis that RSD is the result of an exaggerated inflammatory response to injury or surgery.

Algodystrophy is characterized initially by an increase in arterial flow, an increase in blood pool, a decrease in microcirculatory velocity, and a loss of thermoregulatory control. These changes, producing the typical symptomatology, associated diffuse hand pain, diminished hand function, edema, and abnormal color and temperature, are believed now to correspond in most cases to an exaggeration of the normal post-traumatic inflammatory responses and are not the consequence of sympathetic damage. Algodystrophy may be prevented in most hand surgery patients by minimizing the normal postoperative inflammation, by increasing venous return (especially by avoiding plaster casts and constrictive dressings), by controlling post-traumatic pain, by promoting early active mobilization, and by reassuring the patient. If there is any sign of algodystrophy, three-phase bone scintigraphy should be obtained and treatment instituted immediately.

RSD can be approached using objective criteria in a logical and systematic fashion. Frustration during treatment is common because (1) the pathophysiology of RSD is incompletely understood, (2) there is significant variation in presentation because of disparate premorbid anatomy and physiology, and (3) the natural history may be affected by incomplete treatment. Therapeutic efforts that theoretically should be effective may fail, and a trial-and-error approach is often mandatory. In spite of vigorous intervention using all known strategies, patients may continue to have pain and disability that progresses to stiffness and arthrofibrosis. Early recognition and prompt intervention, however, provide the best opportunity for clinical improvement.

Early diagnosis of RSD is essential. A keen clinical awareness of this problem is required by all hand surgeons. RSD is a clinical diagnosis that may be supplemented by digital temperature, three-phase bone scan, and digital radiographs of the hand. A thorough examination is necessary to identify untreated or inadequately treated sources of RSD. Once diagnosed, prompt treatment of RSD is beneficial. Patients are referred to our anesthesia department for diagnostic and therapeutic stellate ganglion blocks. A trial of 2 to 3 blocks is attempted initially. After successful block is performed, as measured by a Horner's sign and extremity temperature, the patient is brought to the hand clinic where active range-of-motion exercises are started. A stress loading program is an important and essential part of our treatment protocol. Sympathetic blocks are performed on a biweekly basis until the pain is relieved. Consideration is given to long-acting stellate ganglion blocks with a continuous catheter infusion for patients who show a limited, but short-lived response to stellate ganglion blocks. For RSD that does not respond to the stellate ganglion block, we generally perform a bretylium intravenous regional block. Patients with RSD are referred to our hand psychologist for counseling, psychotherapy, relaxation therapy, and possibly biofeedback. We use a multitherapy approach with all available modalities to achieve the best success in breaking the cycle of pain and returning the patient to normal, productive function.