Practical Plastic Surgery

602 Practical Plastic Surgery

and palmar fibromatosis. Sympathetic blockade should eliminate some or all of these symptoms; however this is not always the case.

The hallmark of RSD is pain. The pain is out of proportion to the exam and is often described as severe burning that lasts long after the stimulus is removed. Pain with light touch is common as well. Extreme sensitivity to cold is a frequent complaint. This can be tested by applying a drop of acetone or ethyl chloride spray to the sensitive area. Nevertheless, RSD patients have used the gamut of terms to describe their pain, including sharp, dull, crushing, cramping and aching. Edema of the affected extremity is common. Joint stiffness to both active and passive motion has been described. The stiffness can be profound. Motion produces pain, resulting in decreased movement of the joint and subsequent decrease range of motion. Discoloration can range from an intense red to a gray, ashen color, and the color often changes during a single examination. The dorsal surface is more characteristically erythematous in appearance, whereas the palmar surface is more likely to be cyanotic or bluish in color.

Trophic changes most commonly manifest with a glossy, shiny appearance to the skin. The subcutaneous tissue can atrophy as well. Decreased capillary refill can occur as a result of vasomotor instability. Conversely, rapid capillary refill can be seen. The affected side should always be compared to the normal one. Furthermore, the involved side is often colder or warmer than the contralateral side. Hair growth is often dramatic. Hyperhydrosis is common early in the course of RSD, and dryness in the later stages. Osteoporosis of any of the bones in the arm or hand can be seen. Plain films of the hand are an important diagnostic test. Finally, nodules and hardening of the palmar surface can be seen, similar to that of Dupuytren’s disease.

There is controversy regarding the existence of an RSD-prone personality. Many of these patients will have some sort of personality disorder or psychiatric disturbance, such as hypochondria, depression or anxiety.

Triphasic Bone-Scans

This is probably the best diagnostic test for RSD. The three phases of this scan are the arterial phase, the venous or blood pool phase, and the metabolic phase. A diagnosis of RSD is supported by increased perfusion in the first phase, increased venous pooling in the MCP and digits during the second phase, and asymmetric uptake in the joints of the affected side in the metabolic phase. There is debate as to which phase of the scan is most important in the diagnosis. Increased tracer uptake in all the joints of the affected hand during the third phase has yielded the highest sensitivity and specificity. In summary, the triphasic bone-scan is a good study for confirming late, severe cases of RSD. However, it has not proven to be sufficiently accurate in diagnosing the very early stages of RSD.

Sympathetic Blockade

The response to sympathetic blockade is both diagnostic and therapeutic. A stellate ganglion block is given with success of the block confirmed by warming of the

101extremity and a Horner’s syndrome. If the patient reports symptomatic improvement in response to the block, the diagnosis of RSD is confirmed. Lack of a response, however, does not exclude RSD. In summary, individuals who do not meet the criteria for RSD or SMPS should be approached with the notion that they suffer from some form of complex regional pain that is not sympathetically maintained and cannot be treated by sympathectomy.

Intravenous alpha-Adrenergic Blockade

Bier block administration of intravenous phentolamine, an alpha-adrenergic receptor antagonist, should produce sympathetic blockade. If the signs and symptoms are sympathetically-mediated as in the case of RSD, they should diminish in response to this infusion. It is important to administer saline in a blinded fashion to eliminate the placebo effect.

Classification

•Lankford classified RSD into five categories:

•Minor causalgia: A mild form of RSD seen after injury to a sensory nerve in the forearm, hand or fingers.

•Major causalgia: The more severe form of causalgia in which pain and dysfunction are prominent. It occurs as a result of injury to mixed motor and sensory nerve.

•Minor traumatic dystrophy: Mild RSD with an inciting trauma, but no known nerve injury.

•Major traumatic dystrophy: The form most commonly thought of when the term RSD is used. Seen after trauma or fracture of the upper extremity, without specific nerve involvement.

•Shoulder and hand syndrome: RSD due to remote injury such as an MI or cervical spine injury. Symptoms begin in the shoulder and spread to the hand, sparing the elbow.

•SMPS can be classified into Type I and II:

•Type I: What is thought of when the term RSD is used. Pain follows and inciting event and is out of proportion to the exam. The other findings typically associated with RSD are usually present.

•Type II: This type of SMPS describes causalgia, similar to the definition given in the Lankford classification.

Staging

•RSD can also be thought of in terms of its stage: early, established or late.

•Early RSD: Defined as the first three months of symptoms. Pain is often burning and can be caused be even light touch. Discoloration, hyperhydrosis, and increased temperature are often present.

•Established RSD: Defined as the period between three and twelve months of symptoms. Pain is still the dominant feature. Skin dryness, joint stiffness, contractures and osteoporosis are common. The temperature of the hand gradually goes from warm seen in early RSD to cold, as compared to the other side.

•Late RSD: Defined as the final stage of RSD, twelve months or longer after onset of symptoms. The pain may become less severe during this stage, however flare-ups can occur. Stiffness and joint contracture are the most prominent features of late RSD. The skin can become thickened and nodular, and severe osteoporosis is not uncommon.

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Treatment

The overriding goal of treatment for RSD is elimination of persistent sources of pain. Simple measures such as relieving pressure points or elevation of the extremity can be very helpful. Local and regional nerve blocks help neutralize sensory nerves as well as providing a chemical sympathectomy.

The stellate ganglion block is the most effective regional nerve block. It has been demonstrated to provide some degree of relief; however results are variable. Numerous studies have been published with good results ranging from zero to 100%. However, little long-term data is available, and few studies are randomized. A satisfactory block is indicated by warming of the upper extremity and a Horner’s sign (unilateral pupillary constriction, ptosis, anhydrosis and facial flushing). Conventional stellate blocks are done with lidocaine or bupivicaine. Good results have been obtained with narcotic blocks (e.g., fentanyl) in refractory cases. Usually repeated biweekly blocks are required. For patients unable to tolerate weekly treatments, a continuous stellate block for 3 to7 days has been used successfully.

Although not widely used in the U.S., sympathetic inhibition can also be achieved using an intravenous regional block with anti-adrenergic agents such as bretylium, guanethidine or reserpine. These agents are infused intravenously into an extremity using the Bier block technique to isolate the upper extremity. Other drugs such as steroids and NSAIDs have been used as well. Good long-term pain relief has been demonstrated with this technique.

A variety of oral medications have been used to treat RSD. Several drug regimens, such as a short course of oral corticosteroids, nightly amitryptyline, and select calcium channel blockers have met with good success. Oral phenoxybenzamine and other anti-adrenergic drugs have been used with mixed results. Calcitionin and phenytoin have been used to relieve symptoms of RSD; however their use has met with mixed results.

Physical therapy should consist of active range of motion of all joints from the shoulder to the DIP joints. Hand therapy should not be done while the patient is actively in pain. It can be performed immediately following sympathetic blocks when substantial pain relief has been achieved. Progressive stress loading without joint motion is also recommended. It involves the use of active traction and compression exercises. Static splints can be used to keep the hand in the intrinsic plus position.

Adjunctive treatments can be helpful in dealing with RSD that does not respond to traditional sympathetic blocks and hand therapy. Biofeedback, psychotherapy, smoking cessation, and transcutaneous electrical nerve stimulation have all been attempted.

Surgical sympathectomy should be reserved for severe, prolonged cases, and those that are refractory to other treatment modalities. The procedure consists of transection of the upper thoracic sympathetic chain via an extrapleural, axillary approach. The T2 and T3 sympathetic nerves must be completely transected. Success rates up to 90% have been reported. More recently, sympathectomies have been performed under video-assisted thoracoscopic surgery (VATS).

Long-Term Outcomes

Very few studies have addressed the sequelae of patients successfully treated for RSD. Overall, long-term results have been disappointing. At one year post-treatment, roughly half of patients have cold intolerance or pain with cold

101weather. Trophic changes persist in about a third of patients. Joint swelling and stiffness, as well as decreased grip strength are also common complaints. In summary, RSD and SMPS are still poorly understood. The diagnosis of these conditions can be challenging, and their treatment even more so. Active and future research will undoubtedly shed greater light on these syndromes and offer promise for those who suffer from them.

Pearls and Pitfalls

1.It is important for the treating physician to realize that almost any injury can be the inciting cause for RSD. The earlier the inciting injury is recognized, the more likely treatment is to be successful.

2.Pain free movement is probably the best therapeutic modality against RSD. Nerve blocks and oral analgesics combined with physical therapy is a treatment goal.

3.The extremity surgeon treating this condition is a coach or motivator for the patient, more so for this disease process than almost any other. The patient needs frequent counseling about the disease process and the expected length of treatment.

Suggested Reading

1.Dzwierzynski WW, Sanger JR. Reflex sympathetic dystrophy. Hand Clin 1994; 10:29.

2.Lankford LL. Reflex sympathetic dystrophy. In: Hunter JM et al, eds. Rehabilitation of the Hand-Surgery and Therapy. 3rd ed. St. Louis: CV Mosby, 1990.

3.Nath RK, Mackinnon SE, Stelnicki E. Reflex sympathetic dystrophy. The controversy continues. Clin Plast Surg 1996; 23:435.

4.Zyluk A. The sequelae of reflex sympathetic dystrophy. J Hand Surg (Br) 2001; 26:151.

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•Unilateral subcostal incision (Kocher incision) for an ipsilateral flap based on the superior pedicle

•Bilateral subcostal incisons (Chevron incision) for any flap based on the superior pedicle

•Low transverse incison (Pfannenstiel incision) for any muscle flap based on the inferior pedicle (exception: a deep inferior epigastric perforator flap)

•Any portion of the skin island that is lateral to a prior skin incision should not be used

•Prior use of the internal mammary artery is a relative contraindication for a superiorly based flap

•History of major external iliac vascular surgery is a relative contraindication for

an inferiorly based flap, unless angiography confirms otherwise.

For harvesting a muscle flap, either a longitudinal paramedian or low transverse skin incision is used. For the musculocutaneous flap, the skin island can be marked in multiple horizontal or vertical patterns. A transverse (horizontal) skin island can be up to 21 x 8 to 21 x 14 cm in size. This skin can be divided into zones: zone 1 is over the ipsilateral rectus; zone 2 is over the contralateral rectus; zone 3 is lateral to the ipsilateral rectus; zone 4 (least reliable skin) is lateral to the contralateral rectus.

After the skin paddle is marked, the inferior border is incised down to the anterior rectus sheath. The skin and subcutaneous fat are elevated from lateral to medial off the fascia. The dissection is slowed several centimeters lateral to the midline where the musculocutaneous perforators are encountered. The superior border of the skin island should be incised only after confirming that the donor skin will close without excessive tension. Alternatively, the superior incision can be made first, followed by the inferior incision once it is clear that the abdominal skin will come together without undue tension.

The anterior rectus sheath is opened sharply in a longitudinal direction exposing the rectus muscle (Fig. AI.2). The muscle is dissected free from its sheath, with care taken not to violate the posterior sheath. For the inferiorly-based flap, the muscle is divided at or near the costal margin. The superior epigastric artery and vein are divided at the medial border of the muscle. For the superiorly-based flap, the muscle is divided at the level of the pubis symphysis. The deep inferior epigastric artery and vein can be dissected for several centimeters prior to division. This can serve as an alternative pedicle for microvascular anastomosis if the superior pedicle is insufficient. Care must always be taken to avoid injuring the musculocutaneous perforators feeding the skin paddle.