Health: It all began with just a broken ankle: A too-tight plaster cast can trigger an agonising condition from which few recover. One sufferer talks to Margaret Park

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IN APRIL 1990, while on holiday in Australia, Jeannie Fraser-Allen, then 44, spent a day riding on a friend's property. An experienced rider, she sensed as she negotiated a creek that her horse was about to fall and quickly jumped from his back. What happened next is unclear. 'The horse fell and as he got up he must have kicked me,' Mrs Fraser-Allen says. 'I was stunned and can't recall the details, but I do remember enormous pain in my ankle.'

A fractured ankle, which might normally be expected to heal in a couple of months, left Mrs Fraser-Allen crippled for three years. She is still in constant pain and believes that a straightforward fracture was turned into permanent damage to her leg by a plaster cast fitted too tightly.

'I was screaming in pain after coming out of theatre. I kept saying the plaster was too tight. It was very painful and my toes were dark red.'

She was advised not to travel for several weeks and eventually returned to England six weeks later. 'By then my leg had become very thin, the toes were purple and it was still very painful,' she says.

She had planned to wait for the return of a recommended surgeon from holiday, but driven to distraction by the pain, she went instead to an orthopaedic surgeon at a private London clinic.

'I'd hardly been in the room a couple of minutes before he said: 'We must take this off at once'. When he had finished cutting off the plaster he went and whispered in a corner with his assistant.

'My leg was completely purple from hip to toe and much thinner than the other one. There were three deep indentations where the plaster had dug in: along the side of my foot, under the instep, and on the back of my leg. There was no movement in the ankle at all.'

She was diagnosed as having reflex sympathetic dystrophy (RSD), also known as Sudeck's atrophy, in the affected limb, a rare injury to the nervous system for which there is no known cure. Typically, sufferers experience enormous pain, soft-tissue swelling and circulatory changes, which turn the skin purple. Stiffness and deformity follow, leading to osteoporosis or thinning of the bone.

'I heard the word amputation muttered in my vicinity. I think they were using it as psychological pressure to get me to work my leg,' she says.

Her doctor may not have been only trying to shock, because he later admitted that he had at first thought she would never move her foot again. He would also have been aware that sufferers from reflex sympathetic dystrophy often do not recover and can be left in permanent pain.

'It can be a devastating injury,' says Mr Thomas Wadsworth, consultant orthopaedic surgeon at St Bartholomew's Hospital, London. 'The cardinal feature is a great deal of pain, and I've never known a case to settle entirely.'

The only treatment is a pain-relieving injection, which acts as a block and thus enables movement, without which affected limbs can wither with disuse.

'It is vital to keep movement if the limb is not to become useless. Blocks enable the patient to undergo physiotherapy,' says Dr John Hannington-Kiff, director of the Pain Relief Centre at Frimley Park Hospital NHS Trust, Surrey. Dr Hannington-Kiff, who is also European adviser to the RSD Association, based in New Jersey, developed a block using the drug guanethidine in the Seventies.

The first recorded case of RSD struck Napoleon after he was shot through the shoulder at Waterloo. Its exact cause is still unknown.

'The paradox of RSD is that it is often triggered by a relatively minor injury. It can certainly be caused by a tight plaster, which is why all patients should be given a printed sheet of paper after the fitting of a plaster cast saying they must return to hospital if there is any pain or colour change in the fingers or toes of the encased limb,' Dr Hannington-Kiff says.

'The only other thing we know is that it is linked to the release of the stimulant noradrenaline from the sympathetic nerve endings.' The drug guanethidine works by preventing the release of noradrenaline, a hormone that acts as a chemical transmitter of nerve impulses.

From the day the plaster came off and the state of her leg was revealed, Mrs Fraser-Allen's life and that of her family changed dramatically. They were forced to move from their four-storey house in west London, in which she would have been confined to the ground floor. Being mobile only on crutches meant she could no longer look after her two daughters, then 15 and 17, or run her business as a fashion stylist. Instead, the family moved to two small flats in a block in central London - one for Mr and Mrs Fraser-Allen and one for their daughters.

'It was terrible shock to the children, but I couldn't possibly have looked after them; they had to learn very quickly to look after themselves. It was awful because really we lost their last years of childhood.'

Since then, she has devoted virtually all her time to intensive exercise. Against medical advice, she began long daily swims almost straight away. She used a muscle-building machine, designed for injured athletes, at a private clinic until her insurance cover ran out and she could no longer afford the fees.

An osteopath realigned her back, which had been twisted by her limp and the use of crutches. He also recommended a trainer, Dreas Reyneke, a former ballet dancer who specialises in helping injured dancers by using stretching exercises. He, in turn, recommended a Chinese 'deep massage' technique to build muscle and provide temporary pain relief.

Stamina and perseverance have to some extent paid off. Three years later, her leg has regained its shape and, with concentration, she walks without a limp. Putting weight on the leg has also reversed the osteoporosis. However, she is still in constant pain. Exercise helps to control the discomfort, but makes her a slave to physiotherapy, to which she currently devotes three and a half days a week.

'I was stunned to hear that the pain may never go away,' she says, 'because I did hope there was light at the end of the tunnel. And all this might have been avoided if the Australian doctors had listened to my complaints about the plaster.'

(Photograph omitted)

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