Preventing CRPS after wrist fracture

The last post described a new paper in BMC Neurology suggesting guidelines for the treatment of CRPS. They also discussed prevention. They concluded that people who fracture their wrist should be given 500 mg daily vitamin C because two RCT’s show a reduction in incidence of CRPS in those who do this[1,2] both papers from the same group as the guidelines paper.  This is good and well, but I am intrigued about the incidence data from these RCT’s – in the first, those who were untreated had an incidence of CRPS of about 25% and in the second RCT it was about 11%. The treated group incidence was about 2% with confidence intervals easily covering more conservative, and I would suggest probably more accurate, estimates of incidence – about 3-4%.  So,  were these groups of wrist fracture patients really 2-4 times more likely to develop CRPS than other study groups are, or were the criteria by which someone was said to have CRPS different? I would argue the latter here, which is why I think we really don’t know if vitamin C reduces incidence until we show it to do so in a group for whom the untreated people have an incidence of about 3-4%.
grey Preventing CRPS after wrist fracture
[1] Zollinger PE, Tuinebreijer WE, Kreis RW, & Breederveld RS (1999). Effect of vitamin C on frequency of reflex sympathetic dystrophy in wrist fractures: a randomised trial. Lancet, 354 (9195), 2025-8 PMID: 10636366

[2] Cazeneuve JF, Leborgne JM, Kermad K, & Hassan Y (2002). [Vitamin C and prevention of reflex sympathetic dystrophy following surgical management of distal radius fractures] Acta orthopaedica Belgica, 68 (5), 481-4 PMID: 12584978

Comments

  1. Very ordinary information but people generally avoid it. Thanks a lot for reminding to do not make such silly mistakes.Proactol Review

  2. Zollinger 2007 study. Comments may interest.
    http://www.ejbjs.org/cgi/content/abstract/89/7/1424

  3. simple one yet not to ignore

  4. Zollingner’s research was not funded by a profitable entity. I like that. http://www.ncbi.nlm.nih.gov/pubmed/19840748
    The American Association of Orthopaedic Surgeons refers to use of vitamin c for prevention of continued pain. The refer to the research as medium level evidence. http://orthopedics.about.com/gi/o.htm?zi=1/XJ&zTi=1&sdn=orthopedics&cdn=health&tm=5&f=20&tt=12&bt=1&bts=0&zu=http%3A//www.aaos.org/Research/guidelines/DRFguideline.asp

    See recommendation 26 http://www.aaos.org/Research/guidelines/drfsummary.pdf

    Here is a more recent French study about the use of vitamin c for prevention of CRPS Type I for foot and ankle surgery. http://www.ncbi.nlm.nih.gov/pubmed/19840748

    In further study by Zolligner published 2010 in the Open Orthopaedics Journal
    http://www.bentham-open.org/pages/content.php?TOORTHJ/2010/00000004/00000002/71TOORTHJ.SGM
    It concluded that external fixation doesn’t necessarily lead
    to a higher incidence of CRPS in distal radial fractures. In their
    opinion vitamin C lowers the incidence of CRPS in nonoperatively
    treated wrist fractures and may also play a role in
    operatively treated wrist fractures. This subgroup analysis in
    operated distal radial fractures showed no CRPS occurrence
    with vitamin C prophylaxis and gave further arguments for a
    new prospective study to gather a large number of patients for
    sufficient statistical analysis. (I heard from Dr Zolligner a few years back that a problem with a small country is getting a big enough sample for research. This was in relation to my question about research into vitamin c as a treatment for CRPS.) Again this study was funded by a grant from “Stichting
    Achmea Slachtoffer en Samenleving (SASS)”, a Dutch
    foundation for encouraging research objectives in relation to
    ‘aid to victims’.