Medical rehabilitation of a patient with CRPS type I after tibial plateau fracture and sprain of the ankle: A case report and Literature review

Complex regional pain syndrome is a clinical syndrome characterized by chronic, severe, neuropathic pain, which is associated with sensory, trophic, and autonomic disorders and decreased range of motion of the affected joint. Symptoms begin at a variable interval, at least 6 weeks after a traumatic event or after surgery. The evolution of symptoms is unpredictable, as they can range from complete and self-limiting resolution to significant chronic pain with decreasing limb function and quality of life. Depending on the absence or presence of a well-identified neural lesion, types I and II of CRPS can be observed. Because it is a relatively rare condition, it can be overlooked due to the limited experience that doctors have with this one.

A 61-year-old male patient presented with severe pain 9/10 on the Visual Analogue Scale (VAS) and a significant decrease in mobility after suffering a traumatic fracture with a left tibial plateau fracture 4 months before, which required orthopedic treatment with a plate and screws, and a left ankle sprain. Previously, the patient presented to several emergency services where he received anti-inflammatory and analgesic treatment with gradual aggravation of pain and impaired mobility of the left lower limb, walking being possible only on two axillary crutches. The patient received treatment that combined drug therapy with medical rehabilitation exercises and physical therapy agents, with a favorable evolution. At the time of discharge, the pain was 5/10 on the VAS scale and the patient could move with a single Canadian crutch.