Review Question - QID 211600

This patient's chronic and diffuse pain symptoms are consistent with fibromyalgia. Patients with fibromyalgia who sustain distal radial fractures (DRF) are at an increased risk of developing chronic regional pain syndrome (CRPS). Symptoms of CRPS include hyperalgesia, allodynia, and edema.

Fibromyalgia is a common cause of chronic musculoskeletal pain with an increased prevalence in females age 60 to 80. It is characterized by pain in widespread musculoskeletal locations without inciting event. Fibromyalgia and CRPS are similar in that there are no laboratory or radiographic tests that can accurately diagnose either syndrome. Both entities demonstrate alterations in areas of the central nervous system associated with the central processing and modulation of pain, resulting in both diagnoses exhibiting very subjective symptoms. Multiple studies have highlighted an association between fibromyalgia and the development of CRPS following a DRF.

Crijns et al. investigated factors associated with CRPS and how these factors influence care. They reported that among patients recovering from a DRF, female gender, older age, associated ulna fracture, open fracture, and co-morbid diagnosis of fibromyalgia were independently associated with CRPS. They recommended that surgeons practice empathy, more effective communication strategies, and deliver more coordinated care that includes expertise in the functioning of the human mind and human illness behavior when these diagnoses are encountered.

Lipman et al. investigated the association between fibromyalgia and the development of CRPS after DRF. They reported that the prevalence of CRPS following DRF was increased at 3, 6, 9, and 12 months in the fibromyalgia cohort compared with the control cohort. They concluded that fibromyalgia may be a useful predictor of CRPS risk, and as such, should promote increased vigilance for CRPS symptoms and earlier recognition and treatment to improve patient outcomes.

Figure A depicts the characteristic pain at widespread musculoskeletal locations seen with fibromyalgia. Figure B is a radiograph depicting an extra-articular DRF. Illustration A depicts an example of a wrist affected by CRPS, with notably increased swelling, which is a common finding in patients afflicted with the disease.

Incorrect Answers:
Answer 2: Intermittent digital ischemia in cold temperatures is classic for Raynaud's syndrome, which has not been shown to be associated with fibromyalgia.
Answer 3: This describes a positive Spurling's test, characteristic for cervical radiculopathy.
Answer 4: Fingertip ulcerations may be seen in Buerger's disease (thromboangiitis obliterans), which has not been shown to be associated with fibromyalgia.
Answer 5: A pre-ganglion brachial plexopathy would present with Horner syndrome symptoms including ptosis, myosis, and anhidrosis.