Bimalleolar Fracture: A Unique Case of Complication of Complex Regional Pain Syndrome of Lower Extremity After Prolonged Undue Immobilisation

INTRODUCTION: The complex regional pain syndrome (CRPS) is an agonizing and disabling condition that can affect one or more extremities. Contrary to expectation, sporadic case reports about lower limb CRPS are present in literature. The usual sequence of events with respect to CRPS has always been prior trauma or inciting event, leading to manifestations. We hereby present a case of prolonged and undue immobilization without physical therapy, leading to CRPS in a susceptible phenotype. However, the unique feature of this case was severity of osteoporosis leading to bimalleolar fracture. To the best of our knowledge, there has been no case report of CRPS, leading to fracture. CASE REPORT: A 30-year-old female presented 2 months after trauma to the right ankle due to a fall from a bike. A radiograph of the ankle demonstrated no evidence of any bony injury. As per records, there was no evidence of ligament injury based on magnetic resonance imaging evaluation. As the patient had severe pain and swelling, she underwent conservative treatment in the form of lower limb immobilization in a non-weight-bearing below knee splintage for a period of 8 weeks. After removal of the splintage, the patient continued to have severe pain and swelling and was unable to bear weight. At this point of time, the patient presented to our clinic where follow-up radiographs demonstrated a bimalleolar fracture of the right ankle and diffuse osteoporosis involving talus-calcaneusand metatarsals. After thorough exclusion of other metabolic bone diseases based on various laboratory parameters, the diagnosis of CRPS was made as per Budapest criteria. The case here was diligently managed with multidisciplinary approach. It emphasized on the well-designed rehabilitation of the affected extremity to interrupt the vicious cycle of disuse along with well-controlled analgesia, cognitive psychotherapy, and supervised regular physical therapy. Meticulous medical management included bisphosphonates, careful balance of analgesics including nonsteroidal anti-inflammatory drugs, opioids, and beta-blockers. CONCLUSION: This case report highlights the importance of multimodal stepped care approach in CRPS 1 involving ankle joint. Our report also reiterates the relevance of early mobilization and avoiding undue immobilization.