Triple-Phase Bone Scan Inaccurate Diagnosis And Characterization Of Suspected RSD

Reflex Sympathetic Dystrophy or RSD, more appropriately classified as Complex Regional Pain Syndrome (CRPS) type I, is a pain syndrome that usually develops after an initiating noxious event with no identifiable major nerve injury with level of pain is out of proportion to the inciting event or healing response and is associated with edema, changes in skin blood flow and hyperalgesia. The site is usually the distal aspect of an affected extremity, or has a distal to the proximal gradient. A triple-phase bone scan has an adjunct role in the diagnostic assessment of the disease, disease staging, predicting the response to therapy, follow-up and in determining the prognosis of the disorder

99mTc MDP Bone Scan (Triple Phase) in Diagnosis and assessment of suspected Reflex Sympathetic Dystrophy of Upper Limb
This case study highlights the utility of a Triple-phase bone scan inaccurate diagnosis and characterization of suspected RSD in a female patient with a traumatic fracture of the left forearm.

Patient Clinical History:

32 years old Female was referred for the bone scan with a history of traumatic fracture of the proximal ulna, post-surgery with mal-union for 6 months. The patient presented with complaints of pain, edema, and redness of the entire left upper limb. A clinical suspicion of possible RSD was considered and the patient referred for bone scanning for confirmation.

Study Protocols:

A Triple Phase MDP Bone scan was performed with the acquisition of flow and blood pool phases immediately following the administration of a standard dose of 99mTc MDP followed by whole body sweep and regional static images after 3 hours of tracer administration.

Study Findings:

Flow images revealed relatively increased blood flow along the entire left upper limb as compared to that of the right side (Fig 1a. Arrowheads, sides marked as R- Right and L- left). Blood Pool images acquired immediately after completion of flow phase demonstrated relatively increased pooling of tracer along proximal ulna corresponding to the site of mal-united fracture (Fig 1b. Arrow). Additionally relatively increased left upper limb pooling with focal pooling along periarticular regions of left elbow, wrist, MCP and PIP joints were also noted (Fig 1b. Arrowheads).
Delayed static images of upper limbs revealed characteristic periarticular uptake along the left elbow, wrist, MCP and PIP joints (Fig 2. Arrows) in additional to linear heterogeneous uptake along with the site of malunion (Fig 2. Arrowheads).

Whole body bone scan revealed no other significant additional findings (Figure 3).

Case Study Prepared by:

This Bone Scan case study was compiled by Dr. Aashish Gambhir [DRM, DNB] (Nuclear Medicine Physician at House Of Diagnostics Faridabad).

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