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Recovery From Distal Radius Fracture

      To the Editor:
      The review of the effect of Vitamin C on recovery from distal radius fracture by our colleagues Malay and Chung
      • Malay S.
      • Chung K.C.
      Testing the validity of preventing complex regional pain syndrome with vitamin C after distal radius fracture.
      raises more questions than it answers—questions that are worth considering and trying to answer.
      What is the optimal number and diversity of studies on a particular hypothesis before a systematic review or meta-analysis is worthwhile? Is the effect of vitamin C on recovery from distal radius fracture inherently interesting? Or is it only a point of discussion because one enthusiast in The Netherlands performed two trials establishing level 1 evidence that vitamin C lessens the risk of complex regional pain syndrome (CRPS)
      • 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.
      • Zollinger P.E.
      • Tuinebreijer W.E.
      • Kreis R.W.
      • Breederveld R.S.
      Effect of vitamin C on frequency of reflex sympathetic dystrophy in wrist fractures: a randomised trial.
      ? When one enthusiast who generates positive studies is driving the discussion, can a systematic review or meta-analysis actually be counterproductive by reinforcing what may turn out to be inaccurate information?
      Can the diagnosis of CRPS be objectively verified? Is it reliable? Can we base scientific investigations on CRPS? It can be argued that the proposed diagnostic criteria make the diagnosis internally inconsistent and never appropriate.
      • Ring D.
      • Barth R.
      • Barsky A.
      Evidence-based medicine: disproportionate pain and disability.
      For instance, one criterion states there may be no other explanation for the skin changes and stiffness. But avoidance of exercises after injury accounts for all diagnostic criteria.
      • Terkelsen A.J.
      • Bach F.W.
      • Jensen T.S.
      Experimental forearm immobilization in humans induces cold and mechanical hyperalgesia.
      Is there a difference between illnesses like “whiplash”, “hysteria”, “reflex sympathetic dystrophy”, and “CRPS”, and diseases like influenza and lung cancer? According to sociologists, these entities and many others may be social constructions (entities that exist only because a society behaves as if they exist) that ascribe the human illness behavior of disproportionate pain and disability to an elusive pathophysiology.
      • Ring D.
      • Barth R.
      • Barsky A.
      Evidence-based medicine: disproportionate pain and disability.
      It might be that we need more high-level data before we can decide if the role of vitamin C in recovery from musculoskeletal trauma is worth investigating in a systematic review or meta-analysis or if it is a spurious association of one enthusiast. The recent randomized trial of Ekrol and colleagues demonstrated no influence of vitamin C on symptoms, disability, or objective measurements of motion, or diagnosis of “CRPS”, after distal radius fracture.
      • 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.
      We just completed a prospective study that associated ineffective coping strategies (catastrophic thinking) with finger stiffness and delayed after distal radius fracture (unpublished data). Exercises after injury or surgery hurt; and hurt feels like harm. But when patients begin to see that wrist and finger stretches are healthy and pay off, their recovery accelerates.
      In science—particularly systematic reviews of a field with few investigators that may not be dispassionate—it’s important to be careful what questions one asks. Instead of examining vitamin C, the more interesting question is: Why is there such a wide spectrum of pain intensity and magnitude of disability? To date, research consistently identifies mindset (distress and ineffective coping strategies) and circumstances (eg, secondary gain, culture) as the areas we should be focusing on to help our patients recover.
      • Ring D.
      • Barth R.
      • Barsky A.
      Evidence-based medicine: disproportionate pain and disability.

      References

        • Malay S.
        • Chung K.C.
        Testing the validity of preventing complex regional pain syndrome with vitamin C after distal radius fracture.
        J Hand Surg Am. 2014; 39: 2251-2257
        • 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
        • Zollinger P.E.
        • Tuinebreijer W.E.
        • Kreis R.W.
        • Breederveld R.S.
        Effect of vitamin C on frequency of reflex sympathetic dystrophy in wrist fractures: a randomised trial.
        Lancet. 1999; 354: 2025-2028
        • Ring D.
        • Barth R.
        • Barsky A.
        Evidence-based medicine: disproportionate pain and disability.
        J Hand Surg Am. 2010; 35: 1345-1347
        • Terkelsen A.J.
        • Bach F.W.
        • Jensen T.S.
        Experimental forearm immobilization in humans induces cold and mechanical hyperalgesia.
        Anesthesiology. 2008; 109: 297-307
        • 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

      Linked Article

      • Testing the Validity of Preventing Complex Regional Pain Syndrome With Vitamin C After Distal Radius Fracture
        Journal of Hand SurgeryVol. 39Issue 11
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          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.
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      • In Reply:
        Journal of Hand SurgeryVol. 40Issue 1
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          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).
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