Monday, April 22, 2013


A 20 year old man is involved in a bombing and has penetrating injury to his leg. He is taken immediately to the operating theatre and undergoes an above-the-knee amputation of his leg. Post-operatively, he is admitted to the wards, continued on antibiotics, and started on thromboprophylaxis. During the first few days post-operatively, however, the patient continues to have pain at the site of the amputation requiring high doses of IV opiates. The patient points out exactly where the pain is, and injection of lidocaine relieves the pain. The patient is taken back to the OR and a biopsy is shown below.

Challenge 1: What's the diagnosis here?

Excision of the problem relieves the pain and the patient eventually transfers to a rehabilitation facility. However, even in the rehabilitation facility, the patient complains of burning, electric, aching pain in the amputated limb. X-ray does not show any bone spurs, local tissue oxygen tension is normal, and there is no evidence of infection.

Challenge 2: What's the diagnosis here?

First image of woodcut by Hans von Gersdorff is in the public domain, from Wikipedia; second image shown under Fair Use.


Anonymous said...

Phantom pain.

sibogox said...

I don't know what those pathology slides are, i am guessing they are connective tissue biopsy with scar formation i.e. the wavy-looking tissue without any blood vessels around..

Challenge 2 could be psychogenic pain. the pain is the ghost in the face of current medical knowledge. but it definitely isnt a ghost for the patient!

Alex said...

phantom limb?

Craig Chen said...

great job!

The first part of the case describes stump pain from a traumatic neuroma. These form after injury interrupting axons; the pathology shows a disorganized proliferation of axons, Schwann cells, and perineural cells. The second part of the case describes phantom limb pain.

Source: UpToDate.