Case Author(s): M.C.Roarke, M.D., and Keith Fischer, M.D. , 8/7/95 . Rating: #D2, #Q3

Diagnosis: Reflex sympathetic dystrophy

Brief history:

74-year old woman with chronic left ankle pain and no known history of trauma.


Flow images of both ankles, immediate static image of the left ankle and delayed images of the left ankle are shown

View main image(bs) in a separate image viewer

View second image(xr). Plain radiograph of the left foot and ankle.

Full history/Diagnosis is available below

Diagnosis: Reflex sympathetic dystrophy

Full history:

74-year old woman with chronic left ankle pain and no known history of trauma.


21.2 Tc-99m MDP i.v.


Bone scintigraphy shows increased activity on radionuclide angiogram, blood pool, and delayed images throughout the left ankle and foot. The accompanying radiographs dated 6-15-95 reveal marked swelling of the soft tissues of the left foot and ankle as well as diffuse osteopenia. The combined scintigraphic and radiographic findings as well as the clinical history permit a diagnosis of reflex sympathetic dystrophy.


Reflex sympathetic dystrophy, also known as Sudeckšs atrophy and causalgia, is a sympathetic mediated disorder of the extremities characterized by pain, stiffness, swelling, weakness, and skin changes, and vasomotor instability. Radiographically, soft tissue swelling and osteopenia are seen. Scintigraphically, there is increased activity in the affected limb during the radionuclide angiographic and immediate post injection images. Delayed scintigraphy reveals increased activity, diffusely in the hand foot. Treatment strategies include physical therapy and, in refractory cases, neurosurgically created dorsal root entry zone lesion.

References: Resnick. Diagnosis of Bone and Joint Disorders, 2nd edition, 2037-2043.

Differential Diagnosis List

Differential considerations include an infectious etiology such as osteomyelitis, although the diffuse pattern of uptake argues against this. Arthritides such as rheumatoid arthritis and the rheumatoid variants would be expected to be more joint centered. Frostbite or electrical injury might also be considered, but the predominance of proximal foot and ankle involvement rather than distal involvement makes these possibilities less likely.

ACR Codes and Keywords:

References and General Discussion of Bone Scintigraphy (Anatomic field:Skeletal System, Category:Effect of Trauma)

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Case number: bs031

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