CASE STUDY
Mr. R. was a 38 year old firefighter who had been badly burned on both hands whilst fighting a fire some three years previously. His burns had healed without the need for skin grafting, but his right hand had continued to give him pain. He described the pain as 8/10 most of the time, increasing to 9.5/10 if he tried to use the hand. At best it was 7/10. He was sleeping badly. The pain made getting to sleep difficult and he was awakened frequently.
He had tried numerous NSAIDS without effect. He took 12-16 codeine/acetaminophen combination tablets per day. This dose amounted to 6-8 gm of acetaminophen per day. He also took diazepam 10 mg three times a day. He was drinking heavily to "take his mind off the pain" but had no previous history of substance abuse. He described the pain as a continuous burning over his thumb and back of his right hand. Cold or hot packs did not make the pain worse but barometric pressure changes, associated with weather fronts, aggravated his pain. He had had three emergency room admissions over the last six months because of his pain. On each occasion he was given demerol 100 mg by intramuscular injection with marked relief of his pain (10/10 decreased to 5-6/10).
He was married with two children. He had attempted to return to work some six months after his accident. Unfortunately his painful right hand (he was right-handed) prevented him from achieving much productive work and he had stopped work after one month. He had been a firefighter for 12 years and had enjoyed it. He wanted to return to it in some capacity.
On examination he protected his right hand and wore an elasticized glove to decrease the swelling. Nail and hair growth appeared normal. There was normal skin temperature when compared to the left side.
He had marked allodynia (light touch caused pain) over the dorsum of his hand and thumb as well as hyperpathia (a painful stimulation caused pain which lasted significantly longer than the stimulus). He was unable to oppose his thumb and movements of all fingers were decreased by pain and stiffness. Swelling of the hand was not marked.
IMPRESSION:
Chronic pain, possibly conduction pain (radial nerve).
|
