Elsevier

The Journal of Hand Surgery

Volume 39, Issue 11, November 2014, Pages 2251-2257
The Journal of Hand Surgery

Scientific article
Testing the Validity of Preventing Complex Regional Pain Syndrome With Vitamin C After Distal Radius Fracture

https://doi.org/10.1016/j.jhsa.2014.08.009Get rights and content

Purpose

The American Academy of Orthopaedic Surgeons recommends the use of vitamin C to prevent complex regional pain syndrome (CRPS) for patients with distal radius fractures (DRFs). We hypothesized that the evidence for supporting this recommendation is weak, based on epidemiological principles of association and causality. The specific aim of this project was to test the validity of this recommendation.

Methods

We conducted a literature review to retrieve articles reporting on the use of vitamin C to prevent CRPS. Data collected included sample size, study design type, dose of vitamin C used, and outcome measures of association expressed as relative risk (RR) and odds ratio. We then applied Hill criteria to evaluate the relationship between vitamin C and CRPS.

Results

We obtained 225 articles from the database search. After the exclusion of duplicates, unrelated articles, editorial letters, and commentaries, we found 4 articles and 1 systematic review relevant to our topic. Six of the 9 Hill criteria were met, and an earlier meta-analysis showed a quantified reduction in CRPS risk. However, criteria like biological plausibility, specificity, and coherence were not met.

Conclusions

The number of causal/association criteria met was adequate to support the scientific premise of the effect of vitamin C in preventing CRPS after DRF. Furthermore, vitamin C administration is of relatively low cost and has few complications unless administered in large doses. Owing to sufficient epidemiological evidence availability, the American Academy of Orthopaedic Surgeons recommendation of vitamin C to prevent CRPS has practical merit.

Type of study/level of evidence

Therapeutic II.

Section snippets

Literature search

The authors searched MEDLINE, EMBASE, and SCOPUS databases for relevant articles using the keywords “vitamin C” or “ascorbic acid” and “complex regional pain syndrome” or “reflex sympathetic dystrophy.” An experienced MPH researcher (S.M.) performed the search, with support from the university medical librarians. Affected condition was not limited to DRF alone, but included other conditions for which vitamin C was used to prevent CRPS development. We did not use any limit on the language of

Literature search

We obtained 225 articles from 3 databases searched. We performed title and abstract search after the exclusion of duplicates. We excluded all unrelated articles, editorial letters, and commentaries. Four studies and 1 systematic review related to the use of vitamin C and CRPS were available for final review. Among the 4 studies, 3 were conducted in DRF patients and 1 was conducted in patients undergoing foot and ankle surgery.8, 19, 20, 21 We included the foot and ankle surgery article to add

Discussion

We tested our hypothesis that there was not enough evidence for AAOS recommendation of vitamin C as a prophylactic against CRPS occurrence. Our analysis of studies showed that 6 of the 9 Hill criteria were met.14 Therefore, we rejected our hypothesis. There were a few caveats in the methodology and conduct of the included studies. In addition, criteria like biological plausibility, specificity, and coherence were not met. However, technological advancements may present new findings that will

References (38)

  • J.H. Geertzen et al.

    Reflex sympathetic dystrophy: early treatment and psychological aspects

    Arch Phys Med Rehabil

    (1994)
  • S. Bruehl et al.

    External validation of IASP diagnostic criteria for complex regional pain syndrome and proposed research diagnostic criteria. International Association for the Study of Pain

    Pain

    (1999)
  • O. Traxer et al.

    Effect of ascorbic acid consumption on urinary stone risk factors

    J Urol

    (2003)
  • G.C. Curhan et al.

    A prospective study of the intake of vitamins C and B6, and the risk of kidney stones in men

    J Urol

    (1996)
  • L.M. Berglund et al.

    Complications of volar plate fixation for managing distal radius fractures

    J Am Acad Orthop Surg

    (2009)
  • R.M. Atkins et al.

    Features of algodystrophy after Colles' fracture

    J Bone Joint Surg Br

    (1990)
  • R. Arora et al.

    Complications following internal fixation of unstable distal radius fracture with a palmar locking-plate

    J Orthop Trauma

    (2007)
  • P.E. Zollinger et al.

    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)
  • P.C. Amadio

    Vitamin C reduced the incidence of reflex sympathetic dystrophy after wrist fracture

    J Bone Joint Surg Am

    (2000)
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    No benefits in any form have been received or will be received related directly or indirectly to the subject of this article.

    Research reported in this publication was supported in part by grants from the National Institute on Aging and National Institute of Arthritis and Musculoskeletal and Skin Diseases (R01 AR062066), the National Institute of Arthritis and Musculoskeletal and Skin Diseases (2R01 AR047328-06), and a Midcareer Investigator Award in Patient-Oriented Research (2K24 AR053120-06) (to K.C.C.).

    This content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.

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