Presentation
Two months of right upper extremity pain after a shoulder injury. X-rays were normal. Not improving with physical therapy.
Patient Data
A whole body bone scan with spot images of the hands shows abnormally increased radiotracer uptake involving the right hand and wrist in a peri-articular distribution.
Incidental degenerative activity is present under the left patella, medial compartment of both knees and the left 1st metatarsal phalangeal joint.
The frontal view of the right hand was originally interpreted as negative for acute abnormality, but on retrospection, demonstrates subtle decreased mineralization about the metacarpal phalangeal joints and interphalangeal joints.
Case Discussion
Complex regional pain syndrome (CRPS), formerly known as reflex sympathetic dystrophy, is a chronic pain syndrome that accompanies autonomic nervous dysfunction. A diagnosis is usually based on clinical symptoms and signs without an objective diagnostic test. Despite that, several diagnostic tests are frequently employed to support the diagnosis of CRPS. Among them is bone scintigraphy. Typical CRPS shows increased uptake in a peri-articular distribution in the affected limb on the delayed phase (as in this patient). If a three-phase bone scan is performed (TPBS), increased activity is also frequently present in the flow and blood pool images, particularly in the early course of the disease. Radiographs are often normal but may show decreased bone mineralization in a similar peri-articular pattern.
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