The Journal of Bone & Joint Surgery

The Journal of Bone & Joint Surgery, Volume 90, Issue 2

Letters to the Editor | February 01, 2008

Can Vitamin C Prevent Complex Regional Pain Syndrome in Patients with Wrist Fractures?

Benedict A. Rogers, MA, MSc, MRCS; David M. Ricketts, FRCS

Disclosure: The authors did not receive any outside funding or grants in support of their research for or preparation of this work. Neither they nor a member of their immediate families received payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity. No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, division, center, clinical practice, or other charitable or nonprofit organization with which the authors, or a member of their immediate families, are affiliated or associated.

The Journal of Bone and Joint Surgery, Inc.

J Bone Joint Surg Am, 2008 Feb 01;90(2):447-448

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To The Editor:

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Introduction

Introduction | References

To The Editor:

We read with interest the paper "Can Vitamin C Prevent Complex Regional Pain Syndrome in Patients with Wrist Fractures? A Randomized, Controlled, Multicenter Dose- Response Study" (2007;89:1424-31) by Zollinger et al., and we would like to make the following points:

The paper cites an article by Kearns et al.¹ to provide the steady-state level of ascorbic acid (vitamin C) with doses of 200 mg per day. However, Kearns et al. used Sprague-Dawley rats in their study. The muscles were analyzed after three hours of ischemia and one hour of reperfusion. We are not convinced that these data can be used to accurately determine the steady-state level of vitamin C in humans.

Instead, we think that monitoring of plasma vitamin-C levels would have been very useful in the study by Zollinger et al. for many reasons. Such monitoring would have detected noncompliance with regard to taking the medication. Noncompliance was likely to have occurred in the elderly female group studied². Monitoring of plasma vitamin-C levels would also have identified those patients who entered this study with vitamin-C deficiency and those who achieved above-normal serum vitamin-C levels.

The criteria used by the authors to diagnose complex regional pain syndrome were different from those used in other studies^3,4. Thus, it is not surprising that the incidence of complex regional pain syndrome stated in this study differed from those in previous studies.

One symptom (pain) and four signs (skin color, edema, skin temperature, and limited range of movement) were listed as diagnostic criteria for complex regional pain syndrome. It would have been difficult to assess these signs over the telephone at the final one-year assessment as described.

There are many confounding factors that could have affected the outcomes in the different groups. We suggest that the different groups that were studied needed to be corrected for the following variables: the adequacy of fracture reduction or surgical treatment; the compliance rate, known to be low in the elderly²; and the different treatment rates for the different groups studied. Treatment (e.g., physiotherapy or treatment in a pain clinic) improves outcome after the development of complex regional pain syndrome^5,6.

References

Introduction | References

Kearns SR, Moneley D, Murray P, Kelly C, Daly AF. Oral vitamin C attenuates acute ischaemia-reperfusion injury in skeletal muscle. J Bone Joint Surg Br.2001;83:1202-6.831202 2001 [CrossRef]

McElnay JC, McCallion CR, al-Deagi F, Scott M. Self-reported medication non-compliance in the elderly. Eur J Clin Pharmacol.1997;53:171-8.53171 1997 [CrossRef]

Atkins RM, Duckworth T, Kanis JA. Algodystrophy following Colles' fracture. J Hand Surg [Br].1989;14:161-4.14161 1989

Atkins RM, Duckworth T, Kanis JA. Features of algodystrophy after Colles' fracture. J Bone Joint Surg Br.1990;72:105-10.72105 1990

Burton AW, Hassenbusch SJ 3rd, Warneke C, Racz G, Stanton-Hicks M. Complex regional pain syndrome (CRPS): survey of current practices. Pain Pract.2004;4:74-83.474 2004 [CrossRef]

Mak PH, Irwin MG, Tsui SL. Functional improvement after physiotherapy with a continuous infusion of local anaesthetics in patients with complex regional pain syndrome. Acta Anaesthesiol Scand.2003;47:94-7.4794 2003 [CrossRef]

Topics

complex regional pain syndromes ; ascorbic acid ; carpal bone fractures

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Benedict A. Rogers, David M. Ricketts; Can Vitamin C Prevent Complex Regional Pain Syndrome in Patients with Wrist Fractures?. The Journal of Bone & Joint Surgery. 2008 Feb;90(2):447-448.

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