The natural history of post-traumatic algodystrophy
Algodystrophy, particularly in it's less severe form, is a poorly recognised and ill understood condition which, when it occurs after fracture, delays rehabilitation. This study investigated the incidence, natural history and morbidity of post-traumatic algodystrophy. In addition a therapeutic trial of nasal calcitonin was undertaken. Quantitative and semi-quantitative techniques were devised to assess the clinical, skeletal and biochemical features of the condition. Several were shown to be sufficiently sensitive and specific to be of value in assessing the disorder and were applied prospectively to 274 patients who had sustained a Colles' fracture. The features of algodystrophy were significantly clustered (p <0.0001), confirming the presence of a distinct syndrome which affected 28% of patients with Colles' fracture. Six months after fracture, the proportion of algodystrophic patients complaining of swelling had fallen to 20-30%, vascular instability and tenderness to 50%, and stiffness to 80%. These abnormalities were associated with a significant (p < 0.0001) loss of function. At one year stiffness was still apparent in 50% of cases. In the absence of the other features, stiffness would not necessarily be attributed to algodystrophy and may explain the low reported incidence of this condition following fracture. It may, however account, at least in part, for the permanent loss of hand function seen following Colles' fracture. The present survey also showed a more marked and persistent loss of bone in patients with algodystrophy than in Colles' fracture controls. This was associated with a significantly increased uptake on bone scintigraphy and decrease in bone formation as measured by serum osteocalcin. The mechanism causing these skeletal changes and their implications are discussed. Treatment with nasal calcitonin did not alter the natural history of the disorder. This study has shown that post-traumatic algodystrophy is more common than originally thought, is associated with significant short-term morbidity and may be responsible, at least in part, for long-term loss of function after Colles' fracture. In addition, it is associated with a persistent loss of skeletal mass.