A case of complex regional pain syndrome post fracture

Jane is a 39-year-old woman who suffered a nondisplaced fracture of her left ankle twomonths ago. This occurred following a simple fall with no other injuries sustained. She attended hospital promptly for treatment and was managed conservatively with a cast. During the first five weeks following the injury she presented to you, her GP, complaining of increasing pain and swelling from the left ankle. You referred her to the fracture clinic at the hospital orthopaedic department where they decided to remove the cast early. Repeat x-ray of the ankle was performed, which revealed normal bone alignment and good healing of the fracture. The ankle was, however, noted to be erythematous, hot and swollen. Investigations were performed and included full blood count, measurement of urea, electrolyte and C-reactive protein levels, blood culture, D-dimer test and lower limb venous ultrasound scan. Inflammatory markers were normal and no evidence of infection or deep vein thrombosis was found.

The patient was discharged from the orthopaedic department as there was felt to be no ongoing surgical issue. However, nine weeks after her fracture Jane returns to you with severe pain affecting her left leg from the mid-calf down to her toes on the side of the fracture. Her left leg is swollen, erythematous and the skin has taken on a shiny appearance. She has tried taking regular paracetamol, ibuprofen and over-the-counter paracetamol 500mg together with codeine 10 mg with no benefit.