Practice changer
Vitamin C 500 mg daily for 50 days reduced the risk of complex regional pain syndrome for patients with a wrist fracture.
We think vitamin C 500 mg a day for 7 weeks is well worth recommending.1
Strength of recommendation
A: Based on 2 consistent, well-designed randomized controlled trials (RCTs)
Zollinger PE, Tuinebreijer WE, Breederveld RS, Kreis RW. Can vitamin C prevent complex regional pain syndrome in patients with wrist fractures? A randomized, controlled, multicenter dose-response study. J Bone Joint Surg Am 2007; 89:1424–1431.1
Illustrative case
Your patient is an 83-year-old woman who fell at home. radiographs show a distal radial fracture, which is treated with casting. You know that a quarter of patients with wrist fractures will suffer from complex regional pain syndrome, and there is no well-established treatment for it. Is there any way to reduce this woman’s chance of getting this painful syndrome?
BACKGROUND: Often misdiagnosed
We were surprised to learn how commonly patients suffer from complex regional pain syndrome (CRPS) after a fracture.
We think this diagnosis is frequently missed or misdiagnosed. Even with resolution, however, symptoms can be bothersome—and in 1% to 2% of cases, quite severe.
CRPS, a syndrome of pain and autonomic dysfunction after trauma, is divided into 2 types:
- type I has no obvious damage to nerves
- type II is due to definite damage to nerves (causalgia).
The etiology of CRPS (all further references here will be to type I) is still unclear, but not for lack of proposed theories. Sigmund Freud suggested that it has an origin in personality; there is little evidence to support his theory.2
Other theories include microtrauma to nerves, sympathetic nervous system abnormalities (hence the former name, reflex sympathetic dystrophy), abnormalities of the inflammatory response, and physiologic responses to immobilization. It is often described as a biphasic syndrome, with early edema followed by contracture and stiffness. It typically affects the extremities.2
CRPS more likely in women. A population-based study in Olmsted County, MN found an incidence of 5.5 per 100,000 person-years, with a prevalence of 20.6 per 100,000. Women were affected 4 times more than men.3 Fracture (46%) and sprain (12%) were the leading triggers, followed by other injuries, including crush, stroke, and contusion.
“My patients saw me, but i didn’t see them”
Bernard Ewigman, MD, MSPH
Department of Family Medicine
The University of Chicago
Apparently quite a few patients with complex regional pain syndrome (CRPS) saw me during my 20 years of practice, but I did not see them, or at least I did not recognize their symptoms.
As many as 50% of cast complaints—or post-cast complaints—probably represented CRPS. I wrote them off in all but the most severe cases, which were so dramatic they couldn’t be written off.
I vividly remember the suffering those patients experienced, as well as my feelings of helplessness to offer any relief. CRPS is still not treatable, but now we know that vitamin C can help prevent it, or at least shorten its severity and duration. Granted, the symptoms can be mild, and most resolve spontaneously, but it can go on for months and it can be truly horrific in a small percent (1%–2%).
Here is an instance in which an ounce of prevention is worth more than a pound of cure.
Over half of patients may suffer
Despite typically reported rates of 1% to 2% for severe, chronic CRPS following these injuries, it appears that milder cases are substantially more common.
In a cohort of 274 patients with Colles’s fractures, at 2 weeks, 24% met all 4 of the criteria used in the study to define CRPS, specifically:
- tenderness
- vascular instability
- stiffness
- objective swelling of areas distal to and distinctive from the fracture.
Although 48% met none of the criteria, the remaining 28% had at least some of the criteria.4
Most patients recover. Patients with partial CRPS improved more rapidly than those with CRPS; by 5 months, most had recovered completely. Patients with definitive CRPS also improved, although about 65% still reported stiffness in hands and wrists at 5 months. Another cohort study of 100 patients, also with Colles’s fractures, found similar rates of CRPS 9 weeks.5
