School of Podiatric Medicine - Student Research

Document Type

Poster

Publication Date

Spring 2026

Abstract

Purpose: Complex Regional Pain Syndrome (CRPS) is a pain disorder that typically follows several forms of trauma, including surgery or fractures. The diagnostic gold standard for CRPS is the Budapest diagnostic criteria. In the general population, CRPS is 3-4 times more common in middle-aged women. Regarding incidence following injury, it most often occurs after a fracture. CRPS secondary to ballistic trauma is rarer, particularly in the case of a young male individual. The purpose of our case study is to follow a 21-year-old male patient who suffered an accidental self-inflicted gunshot wound to the left foot and detail the presentation and subsequent management of CRPS.

Case Study: The patient is a 21-year-old male who presented to the ED via EMS following a gunshot wound to the left foot with a 9mm caliber bullet which occurred accidentally while cleaning his gun. Initial labs showed elevated WBC at 18.64. Dermatological exam findings showed evidence of a dorsal medial left foot entry wound and plantar medial exit wound with no evidence of purulence. Vascular, neurological, and musculoskeletal exams to the bilateral lower extremities were unremarkable. Radiographs showed evidence of a medial first metatarsal base intra-articular fracture, minimally displaced. Wounds were flushed with 1L of Betadine and 1L of sterile saline, dressed with dry sterile dressing, and the patient was admitted for IV antibiotics and surgical intervention.

Results: The patient underwent surgical intervention consisting of incision and drainage of the left foot and was administered Ancef intra-operatively and prophylactic Clindamycin post-operatively. No evidence of retained bullet fragmentations were noted. The patient remained inpatient for further monitoring for 48 hours and was subsequently discharged with instructions on protected weightbearing to the left lower extremity in a CAM boot. At his first post-operative visit 11 days following the injury, the patient presented with significant continued pain, ecchymosis, and edema to the foot as well as decreased range of motion and guarding to the left ankle and lesser digits. Physical exam findings satisfied the Budapest criteria and suspicion for CRPS type 1 was noted at this time due to continued pain in his toes and ankle, making him unable to move them. No identifiable nerve damage was found.

Analysis & Discussion: Regarding CRPS cases, 40-50% are preceded by fractures and another 30-40% occur following surgical procedures. This case is noteworthy because while it does meet these criteria, it differs in several others that are common risk factors for developing CRPS. It diverges in this case with the patient being of male gender and early in his third decade of life. Also, reported cases of high-energy ballistic injuries resulting in CRPS are rare in literature, and more research is needed to find out if a direct link exists.

Current guidelines for the management of CRPS include a staged approach focused on three factors.

  1. Prevention, including having as little tissue traumatization and immobilization as possible. 
  2. Acute phase/early rehabilitation, which involves symptomatic therapy and providing instructions on using and reintegrating the limb. 
  3. Late rehabilitation/reintegration, which includes promoting autonomy and participation in the patient.

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