0:00

This is a 52-year-old woman, wife of a

0:04

physician, who just slightly twists her

0:07

ankle in a clogged shoe, stepping off the

0:10

curb in front of a coffee shop, and the next

0:12

day, she cannot bear weight on the foot.

0:16

All kinds of diagnoses are postulated.

0:18

All of her imaging is negative.

0:20

She does not undergo bone scintigraphy,

0:24

but she does undergo CT and X-ray and MRI.

0:28

All of which are initially deemed normal.

0:31

These are serially carried out over a

0:32

period of time, and the lack of weight

0:35

bearing and inability to do so persists.

0:38

So approximately six weeks later,

0:41

this MRI is performed again.

0:45

And if you look at the sagittal, it's a low

0:47

field study, if you look at the sagittal along

0:51

the edges of the skeleton, the corners, the

0:55

so-called shiny corner sign that you see in

0:58

ankylosing spondylitis, is present in the foot.

1:04

This appearance was not highlighted

1:08

strong enough for the clinician.

1:11

And the clinician decided that after a protracted

1:14

period of non-weight-bearing, that the problem,

1:17

which was localized, the pain was localized in

1:20

the distribution of the medial plantar nerve

1:25

that the patient needed to have her posterior

1:28

tibial tendon taken off and re-implanted.

1:30

And that indeed was done.

1:32

At re-implantation, the bone was soft and

1:34

difficult to harbor and fix the anchor.

1:39

That tipped a group of physicians off to

1:41

the correct diagnosis, which was complex

1:45

regional pain syndrome type 2, in a nerve

1:49

distribution most likely related to an injury

1:53

of the tibial or medial plantar nerve that

1:55

then germinated into diffuse type 1 RSD.

2:01

This shiny corner appearance

2:03

should have been the tip-off.

2:05

This low signal intensity corner should have

2:07

been the tip-off, but even more important is the

2:13

prominence of the trabecula, which is a sign of

2:17

osteopenia, and there was no other explanation

2:21

for the patient's inability to bear weight.

2:25

Let's see what happens in this condition

2:28

when it goes unchecked on a CT.

2:31

So on CT, unchecked.

2:34

Massive osteopenia.

2:36

And also hypersensitivity on the

2:39

part of the patient to touch.

2:41

Yet still, the patient's foot surgeon refused

2:46

to allow the diagnosis of RSD, even though

2:49

it had been questioned multiple times.

2:52

Finally, the clinician was overridden.

2:56

The patient was taken to an anesthesiologist.

2:59

The patient underwent lumbar block, instantaneous

3:03

improvement in both the vascularity of the

3:06

foot. Decrease in pain, and all of this

3:09

spotty, extensive osteopenia resolved.

3:14

The patient now is normally ambulating.

3:16

But this is how subtle reflex

3:19

sympathetic dystrophy can be.

3:21

It can start out with very subtle, shiny

3:25

corners in the bone and nothing more.

3:27

No soft tissue swelling, no effusion,

3:29

and progress to massive osteopenia

3:33

due to autonomic dysfunction.

3:36

This is a proven case.