Advertisement

In Reply:

      Administration of vitamin C for preventing complex regional pain syndrome (CRPS) after a distal radius fracture (DRF) is an intriguing possibility. CRPS is a devastating syndrome that has no clear etiology other than the hypothesis of sympathetic overtone that can cause chronic pain after a trauma. Owing to the absence of a case definition and an identifiable unified etiology, the diagnosis of CRPS is based on subjective criteria defined by the International Association for the Study of Pain (IASP). Therefore, recent interest in finding a magic potion to reduce the incidence of CRPS after a DRF in the form of vitamin C is an intriguing option.
      However, as the authors aptly noted, the finding of salutary effect of vitamin C is based on two randomized controlled trials (RCTs) conducted at a single center.
      • Zollinger P.E.
      • Tuinebreijer W.E.
      • Breederveld R.S.
      • Kreis R.W.
      Can vitamin C prevent complex regional pain syndrome in patients with wrist fractures? A randomized, controlled, multicenter dose-response study.
      The application of any experimental finding must consider that spurious result is not a concern. Because vitamin C is inexpensive and potentially harmless unless taken in large doses, the presence of any beneficial effect to prevent CRPS makes its use appropriate. Its usage is largely adopted after the recommendation of the American Association of Orthopedic Surgeons for its preventative effect.

      Randy RB. New AAOS guideline addresses distal radius fractures. 2009. Available at: http://www.aaos.org/Research/guidelines/DRFguideline.asp. Accessed March 27, 2014.

      A recent RCT by Ekrol et al represents a unique contribution to refute the affirmative effect of vitamin C on CRPS rate reduction, however.
      • Ekrol I.
      • Duckworth A.D.
      • Ralston S.H.
      • Court-Brown C.M.
      • McQueen M.M.
      The influence of vitamin C on the outcome of distal radial fractures: a double-blind, randomized controlled trial.
      In fact, the study found no beneficial effect in functional outcomes or fracture healing compared with placebo.
      Is the vitamin C situation a unique event that was refuted by subsequent studies? Carpal tunnel syndrome was associated with deficiency of vitamin B6. Several publications from a single center study with selected patients gave hope that ingestion of high doses of vitamin B6 could treat carpal tunnel syndrome, presumably because of vitamin B6 deficiency in this disease.
      • Folkers K.
      • Ellis J.
      Successful therapy with vitamin B6 and vitamin B2 of the carpal tunnel syndrome and need for determination of the RDAs for vitamins B6 and B2 for disease states.
      Subsequent studies found no such relationship between vitamin B6 and carpal tunnel syndrome, however.
      • Spooner G.R.
      • Desai H.B.
      • Angel J.F.
      • Reeder B.A.
      • Donat J.R.
      Using pyridoxine to treat carpal tunnel syndrome. Randomized control trial.
      In fact, large doses of vitamin B6 can cause harmful effects including sensory and motor neuropathy. Therefore, the message of the vitamin B6 saga is an interesting discussion for two different issues. The first issue is the unknown etiology of a syndrome (CRPS) that does not have a firm diagnostic criteria and established pathophysiology. The second issue relates to a single-center study that appears to advocate a rather unobtrusive treatment of a complex disease that may be too simplistic in its concept. Replication of this study by applying a clinical trial refuted this association. Therefore, the essence of this discussion is that vitamin C may not have scientific evidence to prevent CRPS associated with DRF treatment, although giving this simple remedy to patients may make the surgeons and the patients feel better that they are doing something to avoid this devastating complication. By including this latest study in the pooling of the data, the effect of vitamin C in reducing CRPS incidence may be less convincing.

      References

        • Zollinger P.E.
        • Tuinebreijer W.E.
        • Breederveld R.S.
        • Kreis R.W.
        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. Randy RB. New AAOS guideline addresses distal radius fractures. 2009. Available at: http://www.aaos.org/Research/guidelines/DRFguideline.asp. Accessed March 27, 2014.

        • Ekrol I.
        • Duckworth A.D.
        • Ralston S.H.
        • Court-Brown C.M.
        • McQueen M.M.
        The influence of vitamin C on the outcome of distal radial fractures: a double-blind, randomized controlled trial.
        J Bone Joint Surg Am. 2014; 96: 1451-1459
        • Folkers K.
        • Ellis J.
        Successful therapy with vitamin B6 and vitamin B2 of the carpal tunnel syndrome and need for determination of the RDAs for vitamins B6 and B2 for disease states.
        Ann NY Acad Sci. 1990; 585: 295-301
        • Spooner G.R.
        • Desai H.B.
        • Angel J.F.
        • Reeder B.A.
        • Donat J.R.
        Using pyridoxine to treat carpal tunnel syndrome. Randomized control trial.
        Can Fam Physician. 1993; 39: 2122-2127

      Linked Article

      • Recovery From Distal Radius Fracture
        Journal of Hand SurgeryVol. 40Issue 1
        • Preview
          The review of the effect of Vitamin C on recovery from distal radius fracture by our colleagues Malay and Chung1 raises more questions than it answers—questions that are worth considering and trying to answer.
        • Full-Text
        • PDF