Reflex sympathetic dystrophy.

Early diagnosis of RSD is essential. A keen clinical awareness of this problem is required by all hand surgeons. RSD is a clinical diagnosis that may be supplemented by digital temperature, three-phase bone scan, and digital radiographs of the hand. A thorough examination is necessary to identify untreated or inadequately treated sources of RSD. Once diagnosed, prompt treatment of RSD is beneficial. Patients are referred to our anesthesia department for diagnostic and therapeutic stellate ganglion blocks. A trial of 2 to 3 blocks is attempted initially. After successful block is performed, as measured by a Horner's sign and extremity temperature, the patient is brought to the hand clinic where active range-of-motion exercises are started. A stress loading program is an important and essential part of our treatment protocol. Sympathetic blocks are performed on a biweekly basis until the pain is relieved. Consideration is given to long-acting stellate ganglion blocks with a continuous catheter infusion for patients who show a limited, but short-lived response to stellate ganglion blocks. For RSD that does not respond to the stellate ganglion block, we generally perform a bretylium intravenous regional block. Patients with RSD are referred to our hand psychologist for counseling, psychotherapy, relaxation therapy, and possibly biofeedback. We use a multitherapy approach with all available modalities to achieve the best success in breaking the cycle of pain and returning the patient to normal, productive function.