Sudeck Atrophy

SUDECK ATROPHY (Sudeck) is an acute bone disease described by Sudeck, who, based on the study of the skeleton with X-rays, established in 1900 that acute bone and joint inflammation leads to rapid bone atrophy. In 1901–02, Sudeck proved that acute bone atrophy occurs not only in inflammatory conditions of bone and soft tissues but also after traumatic injuries. At that time, Sudeck proposed a theory considering reflex trophoneurorosis* as the cause of acute atrophy, and for this reason the author named this bone condition "acute reflex bone atrophy." Besides Sudeck's reflex theory, other causes have been proposed as the etiological factor of acute bone atrophy. Among them, the theory of atrophy from inactivity (Inaktivitatsatrophie) was especially supported by Brandes. Opponents of the trophoneurosis theory and supporters of the inactivity atrophy theory see the cause of atrophy in a disturbance of nutrition due to reduced delivery of nutrients. In the works of Kienbock, Kohler, and Embden, the question of acute bone atrophy was subjected to more detailed study. Among the external causes of the development of acute bone atrophy are noted: acute and chronic inflammation of bones and joints, paronychia, phlegmon of tendon sheaths, various traumas and soft tissue contusion, joint contusion and distorsion, fractures of bones and joints, dislocations; further, atrophy is noted upon nerve injury, in some skin diseases (herpes zoster), and in peripheral and central nervous system disorders. Among chronic joint diseases, tuberculosis (tbc) takes first place. Bone atrophy in tuberculous arthritis appears relatively early, when there may still be no gross destructive changes, and in combination with the clinical picture serves as an important sign of the inflammatory condition of the joint. Acute arthritis, especially gonorrheal and septic, is often accompanied by bone atrophy. Regarding trauma, an interesting feature should be noted: trauma can be insignificant but causes significant bone atrophy. Atrophy appears early in frostbite and burns. The time of occurrence of atrophy from the moment of illness or injury varies from 4^1/2 to 10 weeks. In frostbite, Hitschmann and Wachtel established atrophy after 14 and 25 days. After hand trauma, clearly expressed bone atrophy was observed after 6^1/2 weeks. It is difficult to precisely establish the period of atrophy occurrence in tuberculous arthritis, as it is impossible clinically and radiographically to determine the moment of joint tuberculosis. The pathological anatomy of acute bone atrophy is relatively little studied. Exner established that the weight of atrophic bones is significantly reduced: in one of his cases by 30%, in another by 7%, in the third by 67%. Nathaniel and Brooks experimentally established the following. The periosteum separates with difficulty, the cortex becomes porous. The thickness of the cortical layer decreases with simultaneous expansion of the medullary canal, bone trabeculae are significantly thinned and reduced in quantity. Other researchers have established an increase in the number of osteoclasts, under the influence of which there is an intensified resorption process with weak apposition. Consequently, radiographically, atrophy is well established not only due to loss of salts but also due to the disappearance of the bone's basic substance. These processes proceed in parallel: the basic substance is destroyed, and the released salts are resorbed. The phenomena of acute bone atrophy are outlined earlier and more brightly on spongy bones in the distal segments of the limbs and are most clearly established radiographically on the hand and small bones of the foot. But the phenomena of atrophy undoubtedly occur in the central parts of the skeleton and even far from the main focus or the site of direct traumatic injury. - Radiographic picture. Sudeck distinguishes radiologically the acute and chronic stages of atrophy. The initial stage, according to Sudeck, is characterized by uneven spotted illumination, and Sudeck considers this spottedness a characteristic sign of acute reflex bone atrophy. Further works by other authors established that spottedness is not characteristic for determining the type of atrophy: it is noted in any bone atrophy occurring relatively quickly and is explained by pathological-anatomical peculiarities. The resorption process, starting from the medullary and Haversian canals, leads to excavation, thinning, and complete disappearance of individual trabeculae on a certain area of bone, while the rest of the substance temporarily retains a normal structure. Such areas of resorption are obtained on the radiogram in the form of spotted illuminations. Besides spottedness, a lack of clarity of trabecular structure is noted on the radiogram; the image is as if "blurred." In the chronic stage of bone atrophy, sharply outlined contours are noted with thinning of the cortical layer. Clinical picture. In acute bone atrophy, atrophic changes on the part of soft tissues, skin, and muscles are observed simultaneously. In the latter, a decrease in electrical excitability is noted. In most cases, an edematous condition occurs on the hand and foot, almost always there are vasomotor disorders, cyanosis with subjective and objective signs of local hypothermia. Pain and disturbance of function are almost constant signs, and tenderness may persist even when other signs have disappeared. A particularly characteristic picture of such atrophy with prolonged pain is noted in some cases of fracture of the radius (loco classico) and in individual cases of fractures within the ankle joint and foot. An important circumstance in bone atrophy is their brittleness and the possibility of fracture with minimal trauma. Fractures of the femoral neck and supracondylar fractures easily occur. Orthopedists are also aware of fatal cases of fat embolism during reduction of atrophic feet. - There is no specific treatment for bone atrophy. It is necessary to eliminate and treat the underlying disease. In case of hand and finger injury, it is desirable to stimulate the patient for early active movements. Passive movements and rough massage causing pain should be avoided. In fractures, early movements can to a certain extent prevent the development of bone atrophy. Light, painless massage, dry-air baths, and relative rest of the affected limb lead to improvement. For the treatment of bone atrophy in fractures of the radius loco classico, Turner proposed resection of the dorsal interosseous muscle. When atrophy is maintained due to inactivity of the limb, it is necessary to create conditions (by means of a splint or apparatus) for loading, if they do not cause pain. In tuberculosis, bone atrophy persists for a long time. Upon completion of the process, it is desirable to place the limb in conditions of relative physiological load.