Injury, 12, 139-l 44 Printedin GreatBritain
The treatment of Sudeck’s atrophy in the
upper limb by sympathetic blockade
T. H. Dunningham
North Manchester General Hospital, Manchester
Summary
The incidence of Sudeck’s atrophy as a sequel to injury
in the upper limb has been estimated in relation to
casualty attendances in a 3-year period. Seventeen
patients were treated at varying intervals after the
onset of the condition either by stellate ganglion block
or by regional intravenous guanethidine. The results
are compared and the advantages of each method are
discussed.
INTRODUCTION
SUDECK’Satrophy (Sudeck, 1902) is a condition
of chronic persistent pain in any part of the
musculoskeletal system associated with osteo-
porosis and atrophic changes in other tissues and
is often initiated by injury. It has also been
variously named as reflex sympathetic dys-
trophy, post-traumatic painful osteoporosis and,
more recently, algodystrophy. Reports of
Sudeck’s atrophy in the British literature are few
and it has been thought to be rare (Editorial,
1978a), although Plewes (1956) reported its
incidence in the accident services of Luton and
Hitchin. Many large series have been published
(Schumacher and Abramson, 1949; Drucker et
al., 1959) which describe the clinical features in
detail though the pathogenesis remains obscure.
It is generally accepted that sympathetic over-
activity plays a central role in the causation of
the pain and that interruption of the sympath-
etic pathways to the injured limb either by
ganglionectomy, ganglion blockade or by peri-
arterial sympathectomy may produce rapid
resolution of the condition (Drucker et al.,
1959).
Recently, a method of inducing sympathetic
blockade by regional intravenous guanethidine
139
has been described (Hannington-Kiff, 1974).
Guanethidine acts by displacing noradrenalme
from sympathetic nerve endings and then
occupying the noradrenaline storage sites
locally, resulting in sympathetic blockade
lasting a few days. This has been proposed as an
easier and safer alternative to stellate ganglion
block for Sudeck’s atrophy of the upper limb
(Hannington-Kiff, 1977).
Incidence
The incidence of Sudeck’s atrophy in the upper
limb was calculated from the number of cases
seen in a 3-year period in relation to the number
of patients seen with injuries to the upper limb
in the accident and emergency departments.
From 1 January 1976 to 1 January 1979 there
were 153 952 new attendances at the two
accident departments in the North Manchester
District. A study of the registers showed that
approximately 25 per cent of patients attended
with an injury to the upper limb. From these
figures it was estimated that in this 3-year period
38 400 patients came with an injury to the upper
limb.
Sixteen cases of Sudeck’s atrophy were seen at
the fracture clinics following injuries in the
upper limb in this 3-year period. The incidence
of Sudeck’s atrophy is therefore one per 9600
casualties or one per 2400 injuries to the upper
limb.
Sudeck’s atrophy of the lower limb was
diagnosed only once in this period, and it was in
association with the same condition in the hand
in a patient who had an injured ankle as well as a
fracture of the head of the radius.
140 Injury: the British Journal of Accident Surgery Vol. 1 ~/NO. 2

Tab/e/. Patients treated by stellate ganglion block

No. of Residual
Patient Sex Age injury Delay’ blocks Pain relief stiffness Final result

M.T. F 75 Colles’s fracture 8 1 Complete None Good

M.R. F 64 CoUes’s fracture 9 2 Partial Slight Fair
J.R. M 55 Fracture of 12 1 Complete Slight Fair
scaphoid
G.T. M 44 Dislocation of 12 1 Complete None Good
lunate
J.S. F 80 Smith’s fracture 18 1 Complete None Good
M.8. M 31 Colles’sfracture 26 1 Complete None Good
P.F. F 69 Colles’s fracture 30 1 Complete None Good
E.P. F 82 Dislocation of 32 1 No relief Marked Poor
shoulder
O.H. F 55 Soft tissue injury 52 1 No relief Marked f Poor

‘The delay indicated is the number of weeks between the original injury and the start of treatment.

Tab/e Il. Patients treated by regional intravenous guanethidine

No. of Residual
Patient Sex Age Injury Delay blocks Pain relief stiffness Final result

N.H. F 58 Fracture of radial 8 3 Complete Slight Fair

head
A.W. F 61 Soft tissue injury 8 1 Complete None Good
H.W. F 73 Colles’s fracture 9 1 Complete None Good
E.F. F 57 Soft tissue injury 9 1 Complete None Good
K.D. F 47 Fracture-dislocation 10 1 Complete None Good
of shoulder
E.D. F 48 Fracture of radial 11 1 Partial None Fair
head
N.C. F 62 Colles’s fracture 15 1 Partial Slight Fair
M.S. F 79 Colles’s fracture 19 2 No relief Marked Poor
E.P. F 82 Dislocation of 42 1’ No relief Marked Poor
shoulder

lE.P. also had stellate ganglion block at 32 weeks.

PATIENTS AND METHODS Sudeck’s atrophy (Drucker et al., 1959). In 14

Seventeen patients were treated for Sudeck’s
atrophy by sympathetic blockade. Nine patients
were treated as a consecutive series by stellate
ganglion block. A further 8 patients were treated
by intravenous regional guanethidine. One
patient had both types of block. The former
group comprised 6 females and 3 males with an
age range of 3 l-82 years and an average age of
61 years. Further details are shown in Table I.
The latter group consisted of 9 females with an
age range of 47-82 years and an average age of
62 years. Their details are given in Table II.
All cases showed the typical features of
cases there was a definite fracture or dislocation
as listed in Tab/es I and II. In three cases there
had been a blow on the arm or hand which had
resulted in painful bruising only. The pain
experienced by these patients was severe and
continuous and prevented normal sleep. In cases
of fracture it persisted for weeks after normal
bone healing and was felt diffusely in the injured
limb.
Hyperpathia and hyperaesthesiae were pre-
sent in the injured limb in association with the
pain and were similarly diffuse in nature and
persistent. There was limitation of joint move-
 Dunningham: Sudeck’s Atrophy 141

Fig. 1. Swelling of hand and fingers of patient M.R. 9 weeks after Colles’s fracture
(right).

Fig 2. Typical radiological changes 12 weeks after Colles’s fracture (right) in

patient MIS.

ment with a diffuse swelling most marked on the
dorsum of the hand and in the fingers (Fig. 1).
Examination of the palms showed hyperhidrosis
in two-thirds of cases and increased blood flow
in the skin as evidenced by warmth and colour
change in all cases. Comparative radiographs of
the hands in all cases showed the characteristic
changes (Genant et al., 1975) of marked and
punctate osteoporosis area (Fig. 2).
Difftculties in diagnosis occasionally arose in
cases of stiffness after immobilization, acute
median compression and compensation neuro-
sis. The stiffness seen occasionally in the elderly
patient with Colles’s fracture does not have the
severe continuous pain of Sudeck’s atrophy.
Acute median nerve compression could usually
be distinguished by the limitation of pain and
paraesthesiae to the radial three and a half digits.
Cases of functional disorders following minor
injury never conformed to the full criteria given
above, and in particular did not have the typical
pain or signs of sympathetic overactivity,
142
although marked joint stiffness and osteoporosis
could develop.
Stellate ganglion blocks were performed by
the paratracheal route as described by Moore
(1975) using 7 ml of 2 per cent lignocaine with
7 ml of 0.5 per cent marcain. A successful block
was indicated by the appearance of Homer’s
syndrome within a few minutes of the injection
and by vasodilatation and anhidrosis of the
appropriate limb. There were no instances of
failure to achieve sympathetic blockade and no
complications.
Guanethidine blocks were performed accord-
ing to the method of Hannington-Kiff (1974)
with slight modifications. The patients were
sedated with 10 mg of diazepam i.v. and the
resting blood pressure was recorded. A sphyg-
momanometer cuff was applied to the arm
and inflated to above systolic pressure. A
standard dose of 20 mg of guanethidine in 20 ml
of normal saline was then given intravenously
distal to the cuff. Heparin was not used. The cuff
remained inflated for ten minutes. After release
of the cuff, the blood pressure was recorded
every 5 minutes for 20 -30 minutes. In all cases
there was some reduction in blood pressure,
ranging from 10 to 50 mmHg systolic. This was
associated with postural hypotension in a few
cases. The lowest blood pressure recorded was
85150 mmHg; it lasted for 10 minutes and did
not require treatment. All patients were able to
leave the hospital, suitably escorted, one hour
after the procedure.
All patients received a course of physio-
therapy consisting of supervised graduated
exercises and the application of heat by wax
baths. This was commenced at the first sign of
undue joint stiffness and maintained thrice
weekly until the condition improved or
resolved. Sympathetic blocks were always given
in conjunction with physiotherapy.
RESULTS
Three types of response to sympathetic blockade
were seen, differing in the rapidity and degree of
pain relief and the time taken for the resolution
of the physical signs, the most important of
which was stiffness. A good response consisted
of immediate, complete and permanent relief of
pain with the disappearance of stiffness and
swelling within three weeks. A fair response was
characterized by definite but partial pain relief
and in two cases (M.R. and N.H.) the block was
repeated until the relief of pain was acceptable.
Full recovery from stiffness was delayed for at
least six weeks.
Injury: the British Journal of Accident Surgery Vol. 1 Z/No. 2
In the group with a poor response, the relief of
pain was slight and transient. In this group,
stiffness was most marked at the interphalangeal
and metacarpophalangeal joints, where move-
ment was limited to a few degrees and consti-
tuted severe and permanent disability.
Of the 9 patients treated by stellate ganglion
block (Table I), 5 had a good result, 2 had a fair
result and there were 2 poor results. The
patients with a good result were treated at a
mean period of 19 weeks after the injury,
compared with 10.5 weeks for the 2 cases with a
fair result and 42 weeks for the two cases with a
poor result.
In the group of 9 patients treated by intra-
venous guanethidine, there were 4 good results,
3 fair and 2 poor results. The treatment was
carried out respectively 9, 11 and 30 weeks after
the injury. Because of these small numbers,
there is no convincing difference between the
two methods of treatment.
When the results of the two methods are
considered together some general observations
may be made. First, it is clear that the earlier the
block is carried out the better the result, the
mean delay for the good and fair results being
13.2 weeks. No useful benefit was seen from
sympathetic blockade after 30 weeks and,
although 2 good results were seen after stellate
ganglion block at 26 and 30 weeks, this is
unusual in other reported series. Secondly, the
good and fair results differ only in the speed of
recovery, but the poor results show permanent
sequelae.
There were 3 patients with poor results, one of
whom (E.P.) was treated by both methods. Two
were not treated until very late at 32 and 52
weeks (E.P. and O.H.). The third (M.S.) under-
went carpal tunnel decompression 9 weeks after
the Colles’s fracture, and it was only when this
failed to relieve her pain that the diagnosis of
Sudeck’s atrophy was made.
While there were no technical failures or
complications with either method, it was
apparent that blockade with intravenous
guanethidine was easier to perform than stellate
ganglion block. The duration of sympathetic
blockade was consistently longer with intra-
venous guanethidine, 48 hours as compared
with 12 hours after stellate ganglion block.
These two factors make regional intravenous
guanethidine the method of choice, particularly
for the occasional operator.
Both methods of blockade seemed to be
acceptable to patients. Pre-medication is neces-
sary for guanethidine blockade as the pressure of
 Dunningham: Sudeck’s Atrophy
the inflated cuff with ischaemia of the limb for
ten minutes is unpleasant. The maximum
sedative dose found to be necessary was 10 mg
i.v. of diazepam. Pre-medication for stellate
ganglion block may be indicated for a nervous
patient but was not generally used in this series.
Complaints of the recognized side effects of
stellate ganglion block (Moore, 1975) were not
encountered.
DISCUSSION
There seems to be only one report on the
incidence of Sudeck’s atrophy in British civilian
practice. Plewes (1956) found 37 cases in 80 000
patients attending accident departments in a
3-year period. This incidence of one case per
2000 casualties of all kinds is five times greater
than the rate in North Manchester of one per
9600 casualties or one per 2400 upper limb
injuries. The apparent discrepancy may be
accounted for by the difficulties in diagnosing
mild cases which may resolve spontaneously
(Drucker et al., 1959) or with physiotherapy,
and by differences in the populations studied. It
is clear, however, that Sudeck’s atrophy may not
be a rare condition, particularly in view of the
fact that some 20 per cent of injuries seen in
accident departments are to the hand (Rank et
al., 1973).
While the cause of Sudeck’s atrophy remains
obscure, current theories (Loh and Nathan,
1978) at least provide a rational basis for most of
the features of the condition and an explanation
for the efficacy of some therapeutic approaches.
All observers agree that, as in causalgia, there is
an excessive discharge of sympathetic efferent
impulses from the spinal cord. It was proposed
by Doupe et al. (1944) that this sympathetic
efferent activity stimulated somatic sensory
nerves by artificial synapses or ephapses at the
site of the nerve injury in causalgia and a similar
mechanism was held to operate in Sudeck’s
atrophy (Drucker et al., 1959). Recent studies
with regional intravenous guanethidine (Loh
and Nathan, 1978; Hannington-Kiff, 1979) have
shown that the pain of Sudeck’s atrophy or
causalgia may be relieved by this technique even
when the lesion is proximal to the inflated cuff.
This suggests that noradrenaline emitted from
sympathetic nerve endings stimulates somatic
sensory nerves in the periphery of the affected
limb rather than at the lesion per se. Certainly,
one patient in this series (K.D.) had rapid relief
of pain from guanethidine after a fracture-
dislocation of the shoulder. This subject is,
143
however, still under discussion (Editorial,
1978b).
The efficacy of ganglion blocks and intra-
venous regional guanethidine can therefore be
explained in terms of their effect on sympathetic
activity. The efftcacy of physical methods,
intensive exercises, wax baths and cooling
sprays can be explained less readily in terms of
inhibition of sympathetic activity but there is
little doubt that physiotherapy is effective
if instituted early (Plewes, 1956; Drucker et
al., 1959). In this series, however, the majority
of patients had failed to respond to physio-
therapy alone or were unable to cooperate fully
because of the pain. In practice, therefore,
Sudeck’s atrophy should be treated by physio-
theraphy concurrently with effective sympath-
etic blockade.
Acknowledgements
I wish to thank Mr J. M. White for permission to
study his cases and Dr T. White, who performed
the majority ofthe stellate ganglion blocks.
REFERENCES
Doupe J., Cullen C. H. and Chance G. Q. (1944)
Post-traumatic pain and the causalgic syndromes. J.
Neural. Neurosurg. Psyehiatryl, 33.
Drucker W. R., Hubay C. A., Holden W. D. et al.
(1959) Pathogenesis of post-traumatic sympathetic
dystrophy. Am. J. Surg. 97,454.
Editorial (1978a) Algodystrophy. Br. Med. J. 1,461.
Editorial (1978b) The retracted ephapse. Lnncet 2,
462.
Genant H. K., Kozin F., Bekerman C. et al. (1975)
The reflex sympathetic dystrophy
_ _. syndrome.
Radiology 117,i I.-
Hanninaton-Kiff J. (1974) Intravenous reaional block
with guanethidine: La&et 1, 10 19. -
Hannington-Kiff J. (1977) Relief of Sudeck’s atrophy
by regional intravenous guanethidine. Lancet 1,
1132.
Hannington-Kiff J. (1979) Relief of causalgia in limbs
by regional intravenous guanethidine. Br. Med. J. 2,
367.
Loh L. and Nathan P. W. (1978) Painful peripheral
states and sympathetic blocks. J. Neural. Neurosurg.
Psychiatry 41,664.
Moore D. C. (1975)Stellate ganglion block. In: Moore
D. C. (ed.) Regional Block, 4th ed. Springfield, III.,
Charles C. Thomas, p. 128.
Plewes L. W. (1956) Sudeck’s atrophy in the hand. J.
Bone Joint Surg. 38B, 195.
Rank B. K., Wakefteld A. R. and Hueston J. T.
(1973) Surgery of Repair as Applied to Hand
Injuries, 4th ed. Edinburgh, Livingstone, p. 4.
144 Injury: the British Journal of Accident Surgery Vol. 1 ~/NO. 2

Schumacher H. B. and Abramson D. 1. (1949) Sudeck P. (1902) Ueber die akute (trophoneurotische)
Post-traumatic vasomotor disorders. Surg. Gynecol. Knockenatrophie nach Entzundungen und
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Requests.forreprintsshould be addressed10:Mr T. H. Dunningham, North Manchester General Hospital, Manchester

Conference Diary
1980
28 Sept - 3rd World Congress of Bologna, Organizing Bureau,
4 October International Society Italy Studio BC,
for Prosthetics and Via Ugo Bassi,
Orthotics lo-40123 Bologna,
Italy

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22-25 on Immediate Care England British Association
of Immediate Care
Schemes,
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October Symposium on the Rotterdam, Dr J. W. Jultmann,

25 Treatment of Tibia1 Netherlands A. Z. R. Dijkzigt-IOM,
Fractures Dr Molewaterplein 40,
30 15 CD Rotterdam,
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1981
June*t 5th International Brighton, Millstream Conferences Ltd.
17-10 Congress of Emergency England 2 13 Piccadilly,
Surgery London, W 1V 9LD
*First entry.
tFurther details in text.