Can vitamin C prevent complex regional pain syndrome in patients with wrist fractures? A randomized, controlled, multicenter dose-response study.

BACKGROUND: Complex regional pain syndrome type I is treated symptomatically. A protective effect of vitamin C (ascorbic acid) has been reported previously. A dose-response study was designed to evaluate its effect in patients with wrist fractures. METHODS: In a double-blind, prospective, multicenter trial, 416 patients with 427 wrist fractures were randomly allocated to treatment with placebo or treatment with 200, 500, or 1500 mg of vitamin C daily for fifty days. The effect of gender, age, fracture type, and cast-related complaints on the occurrence of complex regional pain syndrome was analyzed. RESULTS: Three hundred and seventeen patients with 328 fractures were randomized to receive vitamin C, and ninety-nine patients with ninety-nine fractures were randomized to receive a placebo. The prevalence of complex regional pain syndrome was 2.4% (eight of 328) in the vitamin C group and 10.1% (ten of ninety-nine) in the placebo group (p=0.002); all of the affected patients were elderly women. Analysis of the different doses of vitamin C showed that the prevalence of complex regional pain syndrome was 4.2% (four of ninety-six) in the 200-mg group (relative risk, 0.41; 95% confidence interval, 0.13 to 1.27), 1.8% (two of 114) in the 500-mg group (relative risk, 0.17; 95% confidence interval, 0.04 to 0.77), and 1.7% (two of 118) in the 1500-mg group (relative risk, 0.17; 95% confidence interval, 0.04 to 0.75). Early cast-related complaints predicted the development of complex regional pain syndrome (relative risk, 5.35; 95% confidence interval, 2.13 to 13.42). CONCLUSIONS: Vitamin C reduces the prevalence of complex regional pain syndrome after wrist fractures. A daily dose of 500 mg for fifty days is recommended.

[Clinical practice guideline 'Complex regional pain syndrome type I']. / Richtlijn 'Complex regionaal pijnsyndroom type I'.

The development and treatment ofthe complex regional pain syndrome type I (CRPS-I) are a subject of much discussion. Using the method for the development ofevidence-based guidelines, a multidisciplinary guideline for the diagnosis and treatment of this syndrome has been drawn up. The diagnosis of CRPS-I is based on the clinical observation of signs and symptoms. For pain treatment, the WHO analgesic ladder is advised up to step z. In case of pain ofa neuropathic nature, anticonvulsants and tricyclic antidepressants may be considered. For the treatment ofinflammatory symptoms, free-radical scavengers (dimethylsulphoxide or acetylcysteine) are advised. In order to enhance peripheral blood flow, vasodilatory medication may be considered. Percutaneous sympathetic blockades may be used for a cold extremity ifvasodilatory medication produces insufficient effect. To decrease functional limitations, standardised physiotherapy and occupational therapy are advised. To prevent the occurrence of CRPS-I after wrist fractures, the use of vitamin C is recommended. Adequate perioperative analgesia, limitation of operation time and limited use of bloodlessness are advised for the secondary prevention of CRPS-I. Use of regional anaesthetic techniques can also be considered in this connection.

Quantification of first tarsometatarsal joint stiffness in hallux valgus patients.

OBJECTIVE: Comparison of the clinical mobility test of the first tarsometatarsal joint with Doppler Imaging of Vibrations measurement of the stiffness of this joint in hallux valgus patients. DESIGN: Clinical testing of first tarsometatarsal joint mobility was related to independent Doppler Imaging of Vibrations measurement of first tarsometatarsal joint stiffness. BACKGROUND: Hypermobility of the first tarsometatarsal joint has consequences for the surgical treatment of hallux valgus deformity. However, the clinical test is subjective. Doppler Imaging of Vibrations could be helpful in quantification of the stiffness of this joint. METHODS: Clinical examination of the mobility of 32 first tarsometatarsal joints in 20 hallux valgus patients was compared with Doppler Imaging of Vibrations stiffness measurements performed by an independent observer. RESULTS: There was a statistically significant relation between the clinical test and the stiffness measurement by Doppler Imaging of Vibrations. CONCLUSION: Doppler Imaging of Vibrations proves to be a method to quantify first tarsometatarsal joint stiffness and could contribute to a rational policy for the surgical treatment of hallux valgus deformity. RELEVANCE: The clinical test to establish hypermobility of the first tarsometatarsal joint is subjective. Doppler Imaging of Vibrations offers objective criteria and quantification of first tarsometatarsal joint stiffness. This provides additional information for the choice of the surgical procedure to correct hallux valgus deformity.

Prenatal ultrasonographic diagnosis of posteromedial bowing of the leg: two case reports.

Congenital posteromedial bowing of the leg was prenatally detected in two pregnancies, at 20 and 31 weeks of gestation. Posteromedial bowing is a rare anomaly of unknown etiology. The prenatal course, monitored by ultrasonography, and the postnatal clinical and radiographic outcomes are discussed and show a complex differential diagnosis. The initial postnatal therapy is conservative. Leg length discrepancy can eventually be treated by lengthening or epiphysiodesis on the contralateral side.

Effect of vitamin C on frequency of reflex sympathetic dystrophy in wrist fractures: a randomised trial.

BACKGROUND: The pathogenesis of reflex sympathetic dystrophy (RSD) is not clear, nor is there a definitive treatment for this syndrome. The morbidity, costs in health care, and loss of work time justify the search for a means to prevent post-traumatic dystrophy. Although the role of toxic oxygen radicals has not yet been clarified, we investigated vitamin C (ascorbic acid) as a prophylactic antioxidant drug. METHODS: 123 adults with 127 conservatively treated wrist fractures were randomly allocated in a double-blind trial to take a capsule of 500 mg vitamin C or placebo daily for 50 days. Each participant's sex, age, side of fracture, dominance, fracture type, dislocation, reduction, and complaints with the plaster cast were recorded, and they were clinically scored for RSD. The follow-up lasted 1 year. FINDINGS: Eight patients were withdrawn after randomisation. 52 patients with 54 fractures (male 22%, female 78%; mean age 57 years) received vitamin C and 63 patients with 65 fractures (male 20%, female 80%; mean age 60 years) received placebo. RSD occurred in four (7%) wrists in the vitamin C group and 14 (22%) in the placebo group 15% (95% CI for differences 2-26). Other significant prognostic variables for the occurrence of RSD were complaints while wearing the cast (relative risk 0.17 [0.07-0.41]) and fracture type (0.37 [0.16-0.89]). INTERPRETATION: This prospective, double-blind study shows that vitamin C was associated with a lower risk of RSD after wrist fractures. Our hypothesis is that this beneficial effect of prophylaxis would be useful in other forms of trauma.