REFLEX SYMPATHETIC DYSTROPHY: THE CONSEQUENCES OF LINDA’S FALL

Linda, a 32-year-old public hospital cleaner slipped on a wet floor and struck her knee. Although she was able to get up with some difficulty and continue working for the rest of the day, she slowly developed more severe pain in her knee. After several months, and having experienced a number of occasions when the knee gave way beneath her, she was referred to an orthopaedic surgeon.

He performed an arthroscopy — passing a thin fibre-optic instrument into the knee — and removed some cartilage and damaged tissue from the back of the kneecap.

It was thought that this procedure would probably alleviate the condition but some months after the operation Linda’s knee was extremely painful. She had also developed a burning sensation in the skin above the knee and had noted that the pain was now present whether she was walking or at rest.

More X-rays were taken and it was decided to do a further arthroscopy. On this occasion it was noted that the back of the patella, or kneecap, showed an erosion, or damage, of the cartilage which normally exists to ensure smooth passage of the kneecap over the thigh bone.

Linda’s damaged cartilage was removed during the arthroscopy and an assurance was given that she would have no more pain. But by then the knee had swollen to several times its normal size and she was only able to walk short distances, with great difficulty.

Meanwhile, she was finding it difficult to look after herself, let alone her family and she had not worked for six months. Linda was then referred to a pain clinic for assessment and treatment. Upon examination it was noted that the affected knee was several degrees cooler than the normal knee. She was also unable to flex or bend the knee in any normal way. It was decided to perform thermography. This confirmed the presence of a reflex sympathetic dystrophy affecting her knee.

Linda was initially treated as an out-patient with an antidepressant medication and TENS therapy. But the depression was so severe that it was eventually decided to admit her to the in-patient program for further treatment and assessment. In the meantime, she was also referred to an orthopaedic surgeon who was an expert in the assessment and treatment of reflex sympathetic dystrophy. He agreed that the treatment Linda was receiving was probably the most appropriate under the circumstances.

During her stay of four weeks in the in-patient program, Linda was taught relaxation techniques and was encouraged to become more active. As part of her rehabilitation, she was to swim regularly and to walk as often as possible.

Meanwhile, her depression was controlled by appropriate medication, the antidepressant Surmontil and also Rivotril. She was seen by an occupational therapist who showed her how to maximise the use of her limb without pain or disability.

By the time she left the in-patient program, Linda was coping extremely well with her pain. She had accepted the fact that there was probably no further surgical intervention that would help her. She had accepted that surgical procedures might even worsen her condition.

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