Case of the Month #9: Persistent Left Arm Pain by Dr Richard Wassall

A 56 year old woman with persistent left arm pain was referred to the pain service from the orthopaedic team. She had been involved in a road traffic accident 2 years ago, and had undergone multiple operations on her left wrist to fix fractures sustained during the impact, and subsequent plate removal. After her final operation 3 months ago, although the bones had satisfactorily healed, she had been left with unrelenting pain which was now affecting most of her left arm and hand. She was finding it increasingly difficult to move her hand and arm despite physiotherapy, so the orthopaedic team increased her analgesia and referred her urgently for a consultation. The patient had limited English, and requested a translator.

The patient’s preappointment questionnaire noted a number of descriptors relating to worsening neuropathic pain with an autonomic component including swelling and redness.  She described difficulty in movement, as well as hyperalgesia and allodynia. The pain was worsening despite increases in her medication by her GP.

At the initial consultant-led face-to-face appointment, the patient walked into clinic cradling her left arm, with her 21-year old daughter who was willing to act as her translator, but an independent interpreter had been booked and accompanied them. Her hand was clawed and looked red. Through the translator, the patient explained how she had recovered well after the first operation, however after subsequent operations the pain had just got worse. She was trying to do her physiotherapy regularly, but when her arm was hot and swollen she found it difficult to move at all. She was unable to dress herself, and preferred to wear short sleeve clothes as anything touching her arm or hand was painful. There were no obvious exacerbating or alleviating factors other than that her pain may get slightly worse on colder days: her perception of her pain was that it was essentially constant and extreme.

She was taking increasing levels of MST (now 40 mg BD) with Oramorph 10 mg PRN (4 - 6 hourly) which had been increased on each hospital visit or GP appointment. She had previously been on 50 mg ON of Amitriptyline, but had suffered with significant sedation and was now tolerating a dose of 20 mg ON. She was not sure if Amitriptyline was helping her pain, but it did help her sleep. 

• Is there any other information you would like to know? 
• What management options might be useful?
• Think about your previous interactions with interpreters. How might you conduct the consultation yourself with an interpreter present?