Lump Flashcards
Background
First described by Weir Mitchell, a civil war surgeon, in the 1860’s
Coined the term causalgia after describing the chronic burning pain his soldiers endured after sustaining nerve injuries
Epidemiology
Described in both adults and children
- The majority of young patients have unusual stress in 1 or more aspects of their life
- Example: family dysfunction
Majority of adult patients are Caucasian
Female predominant
Average age of onset is in the 6th to 7th decades.
Classification
In the past, prior classifications were unclear and confusing
In 1994, the International Association for the Study of Pain ( IASP) established standardized diagnostic criteria for CRPS
Based on description rather than pathophysiology. . . since the etiology is still unclear
Diagnostic Criteria
1. CRPS can be divided into 2 groups:
Type 1- absence of peripheral nerve injury . . . initial event may or may not have been traumatic
- Majority of cases
Type 2- presence of an identifiable nerve injury
Diagnostic Criteria
- Spontaneous pain, allodynia, hyperalgesia occurs, is not limited to the territory of a single peripheral nerve, and is disproportionate to the inciting event.
- History and evidence of edema, skin blood flow abnormalities, or sudomotor abnormalities in the painful region since the inciting event.
- No other concomitant conditions account for the degree of pain and dysfunction.
Pathophysiology
Numerous theories exist, but the exact mechanism remains unclear
Over the years, many theories have tried to explain CRPS’s clinical picture
- sympathetic dysfunction
- central nervous system dysfunction
- peripheral nervous system dysfunction - exaggerated inflammatory response
- genetic predisposition
Pathophysiology
The most popular theory focuses on sympathetic dysfunction!
Pathophysiology
“Vicious Circle” hypothesis
- sympathetic impulses do not shut off, triggering a constant cycle of the inflammatory response
- Consequently, this leads to a continual release of neurotransmitters resulting in increased pain and tissue destruction
Diagnosis
Complex and challenging task
Must have a high index of suspicion
No specific diagnostic test or pathognomonic
symptom associated with an exact diagnosis
Must rely on focused clinical history, physical examination, laboratory tests, and diagnostic modalities
Clinical History
May or may not be able to remember an identifiable traumatic event
- minor as an ankle sprain
- severe as major nerve trauma Most prevailing symptom is pain
- most often described as a burning that can spread beyond the area of initial injury
Clinical History
Pain resulting from a non-noxious stimulus
- allodynia
- example: pressure from bed sheets
Pain that is disproportionate to a noxious stimuli
- hyperalgesia
Physical Examination
May have taken on a guarded posture (dont even let me touch) to shield the affected area
Clinical Manifestations
- vasomotor and sudomotor instability of the affected limb due to sympathetic dysfunction
Physical Examination
Symptoms can range from a warm and erythematous extremity to one that is cool and mottled in appearance
Common manifestations. . . - hyperhidrosis
- edema
- color changes
- temperature changes
Physical Examination
Patient may also experience . . . - muscle weakness
- muscle atrophy
- tremors
- muscle spasms
- decreased ROM
- muscle contractures
Physical Examination
Later in the course of CRPS . . .
Trophic changes to the affected limb can occur including:
- atrophy of the skin - loss of hair growth - hypertrophic or
atrophic nails
Laboratory Tests
Lab tests are important because they can exclude other etiologies
For example: A patient is experiencing vasomotor instability. . .
- blood tests: ESR, CBC, C-reactive protein, RA factor, and ANA
- rule out inflammatory conditions
Stages Stage 1 (days to weeks)
Burned ca ra’s music
Burning throbbing pain with vasomotor instability
Muscle spasms
Radiographs are usually normal
Can be self limiting at this point
Stages Stage 2 (3-6 months)
E M R
Chronic edema pt get’s thick skin
Progression of edema with development of brawny skin (thickening of skin and soft tissue) and toenail changes
Muscle atrophy
Radiographs can begin to reveal spotty osteoporosis
Stages
Stage 3 (after 6 months)
Most co tra limited to na ra
Limitation of movement
Contractures
Trophic skin changes…fat atrophy
Nails become severely dystrophic
Radiographs reveal significant demineralization
Most severe stage
The longer the patient is in stage 3, the more difficult it is to reverse the clinical course of the disease with any type if intervention!!
The longer the patient is in stage 3, the more difficult it is to reverse the clinical course of the disease with any type if intervention!!
Diagnostic Modalities Radiographs
Rule out bone pathology
Can detect osteopenia or “patchy de- mineralization”
Most likely due to disuse of the limb
Known as Sudeck’s atrophy
Diagnostic Modalities
Bone density testing
- evaluate the extent of bone loss
Technetium bone scan
- images the metabolic activity of the
skeleton with a radioactive tracer
- relatively non-specific
EMG/NCV
- rule out nerve entrapment, peripheral neuropathy, or nerve injury- Need neurology consultation!
Diagnostic Modalities Continued
Thermography
- asymmetric difference between limbs
- downside: temperature is dynamic
Resting sweating output and quantitative sudomotor axon reflex test (QSART)
- measure sweat output between limbs
Other tests . . .
Differential Diagnosis
Many disorders can mimic the signs and symptoms of CRPS . . .
- post herpetic neuralgia
- entrapment neuropathy
- cellulitis
- lymphedema
- stress fractures
- bone tumors
- rheumatic and inflammatory arthritis
- connective tissue diseases
- malignancy
- factitious conditions
- many more . . .
Treatment
The primary goal of treatment therapy focuses on restoring limb function.
Treatment
The primary goal of treatment therapy focuses on restoring limb function.
This can be accomplished with physical therapy and pain control
modalities.
Treatment
Successful treatment seems to depend on 5 separate principles . . .
- Patient awareness and commitment
- Capable multidisciplinary team
- Timely diagnosis
- Positive family support
- Sound therapeutic measures
Conservative Treatment Options
Physical therapy is the foundation of treatment
The patient undergoes a series of phases that build upon each other . . .
1. Desensitization and mobilization
2. Regaining flexibility and controlling
edema
3. Isotonic strengthening and stress loading 4. Restoring normal limb function
Conservative Treatment Options Continued
Trancutaneous electrical nerve stimulation (TENS)
Mild electrical current stimulation helps block pain messages short- term
Pharmacological Options
Topical agents
- EMLA
- Lidoderm patch (24h)
- Capsaicin( for diabetes)
Corticosteroids (antidepressant, antiinflamm)
- may suppress ectopic neural
discharges in addition to anti-inflammatory effects
Tricyclic antidepressants (amitriptyline) - inhibits NE and serotonin uptake - unknown mechanism of pain relief
Pharmacological Options Continued
Antiepileptic agents (Gabapentin)-diabetes
- helps prevent the spread of excitation
from a focus of irritability
Opioids
- used sparingly when pain is not
controlled with other medications
Others medications
- muscle relaxants . . .
Procedural Options
Sympathetic nerve blocks
- lumbar block spares motor and
sensory function
- can allow patient to participate in physical
therapy
Sympathectomy
- suppress sympathetic NS activity to affected
area
Electrical stimulation of spinal cord
Implantable pain pump
Prognosis
The prognosis for CRPS varies from person to person.
Spontaneous remission from symptoms occurs in certain individuals.
Others can have unremitting pain and crippling with irreversible changes in spite of treatment.
LUMPS & BUMPS
Ganglionic Cyst - bigger needle is better
Rheumatoid Nodule
Gouty Tophi
Fibroma
Lipoma
Epithelial Inclusion Cyst
Ganglionic Cyst Characteristics** u will see all the time
Freely movable subcutaneous cystic lump or bump… can change size
Well-circumscribed and soft to firm in nature
Fluid filled – consistency of honey/jelly
Generally painless unless nerve
involvement or repetitive trauma
Transilluminate (if it’s cystic, if it’s soluble, wont transilluminate)
Ganglionic Cyst Characteristics continued . . .
Seen over joints or tendons
Involves a flaw in the joint capsule or tendon sheath that allows the joint tissue to bulge out
Multiple small cysts can give the appearance of more than one cyst, but a common stalk within the deeper tissue usually connects them
Ganglionic Cyst
Treatments
Smash☺
Aspirate, inject &compress
Surgical excision
- very high reoccurrence rate
- pink-18gazes, blue-25gazes
- u need bigger needle
- as most proximal as you can get to prevent reoccurence
Rheumatoid Nodule Characteristics
Firm non-tender lump or bump over bony prominences or areas subject to pressure
Often seen under metatarsal heads
Develop in approximately 25% of patients with
rheumatoid arthritis (RA)
Associated with a more rapidly progressive and
destructive disease process
Can ulcerate or become secondarily infected
Rheumatoid Nodule ****
Immune-mediated granulomas with necrotic center
Palisaded histiocytes immediately adjacent to the necrosis
Layer of chronic inflammatory cells
Rheumatoid Nodule
Treatment
- Padding to accommodate
- Shoegear modifications
- Steroid injection
- Excision
Gouty Tophi– 1st mpj
Characteristics
** it can also be in organs
Firm lump or bump over bony prominences
Seen in chronic tophaceous gout
- The development of tophaceous deposits is a function of duration and severity of hyperuricemia
Monosodium urate crystal deposits
Occur in subcutaneous tissues, joints, viscera
May erode bone or ulcerate & drain. . . chalky
in nature
Gouty Tophi
Treatment
-Refer to PCP to lower serum uric acid
-Rarely may need to excise
Plantar Fibroma Characteristics
Firm to hard lump or bump corresponds to a subcutaneous thickening of the plantar fascia
Moves with the fascia/aponeurosis
Most often affects the medial and central
bands
Single or multiple/Unilateral or bilateral
Can become painful on weightbearing
Also called Ledderhose’s disease
Plantar Fibroma
Treatment
- Padding/accommodation with orthotics
- Want orthotics to achieve two things:
- Decrease tension on the plantar fascia
- Decrease pressure on the lump in your arch
Plantar Fibroma
Treatment
- Topical transdermal verapamil
- Calcium channel blocker
- Inhibits fibroblast activity
- No concrete evidence!
- Injection with corticosteroids
- Wide excision is recommended due to the high reoccurrence rate
Lipoma Characteristics
Subcutaneous lump or bump composed of mature fat cells
Rubbery or doughy consistency
Often lobulated
Most often asymptomatic **
Lipoma
Treatment
- Simple surgical excision - Liposuction!!
Epithelial Inclusion Cyst
Characteristics
Firm subcutaneous lump or bump
Other name: epidermoid cyst
Grossly appears like a cocktail onion
Filled with foul-smelling whitish cheesy (caseous) like material. . . keratin
Caused by epithelial cells driven deep into dermis
-surgery -trauma -congenital
Epithelial Inclusion Cyst
The source of this epidermis is nearly always the upper segment of the hair follicle
Inflammation is mediated in part by the horny material/keratinized material contained in epidermoid cysts.
** Extracts of this material have been shown to be chemotactic for poly-
morphonucleocytes.
Epithelial Inclusion Cyst
Treatment
-Incision and drainage
- Excision
- Incomplete excision will lead to reoccurrence
Complex Regional Pain Syndrome
Reflex Sympathetic Dystrophy Syndrome (RSDS)
Other Names Causalgia
Sympathetically maintained pain
Sudeck’s atrophy
Post-traumatic dystrophy
Shoulder-Hand syndrome
Many more names…
Complex Regional Pain Syndrome
Reflex Sympathetic Dystrophy Syndrome (RSDS)
Other Names
Causalgia
Sympathetically maintained pain
Sudeck’s atrophy
Post-traumatic dystrophy
Shoulder-Hand syndrome
Many more names…
