Complex Regional Pain Syndrome
Dr. Tashana Haye
Edited by Rosa Velazquez
Case
50 year old right hand-dominant female presents with wrist pain. She states that 3 months ago she broke her right wrist and it was treated with a cast that she wore for 6 weeks. She followed up with her orthopedic surgeon, who states that she is well healed at this time and she's currently doing physical therapy.
She states that her pain since the injury has been waxing and waning and seems like it flares. Today, her pain is a 10/10 and she cannot move her wrist.
You reorder an X-ray and it appears to be a healed fracture. What does she have? What are your next steps?
Complex Regional Pain Syndrome
CRPS is a complication for conservatively or surgically treated wrist fractures. It is an exaggerated inflammatory response to a traumatic injury due to over-activity of the sympathetic nervous system. This can result in edema, pain, and limitations of range of motion.
There is no curative effective treatment.
ACEP Recommendations
Initial bolus of 0.2-0.3 mg/kg of ketamine infused over 10 minutes.
An infusion of ketamine (0.2 mg/kg/hr) for 4-6 hours
After treatment, the patient can go home. Opioids should be avoided. Refer patient to physiotherapy and a comprehensive pain program.
Can Vitamin C supplementation prevent CRPS-1 after wrist fractures?
Aïm F, Klouche S, Frison A, Bauer T, Hardy P. Efficacy of vitamin C in preventing complex regional pain syndrome after wrist fracture: A systematic review and meta-analysis. Orthop Traumatol Surg Res. 2017 May;103(3):465-470. doi: 10.1016/j.otsr.2016.12.021. Epub 2017 Mar 4. PMID: 28274883.
Article
Methods & Materials
Medline via Pubmed, Cochrane Central Register of Controlled Trials, Embase
Included randomized placebo controlled trials of the efficacy in preventing CRPS-I after a wrist fracture
Primary Outcome: Proportion of patient’s with CRPS-I within one year after the injury
Statistical Analysis Heterogeneity of studies were interpreted. RR with their 95% confidence intervals were computed
Funnel Plot used to assess publication bias
Descriptive stats were computed via GraphPad Prism with which P values <0.5 considered significant
Study Characteristics
All were RCTs with the occurrence of CRPS-I within the first year as the primary outcome.
Patients: 875 total of whom 62.5% received vitamin C and the rest received a placebo
Female/Male ratio: 0.3
Mean Age: 59.6
Wrist fractures
Treatment group:
Extra-articular: 54.8%
Articular: 40.2%
Unclassified: 5%
Placebo group:
Extra-articular: 50.3%
Articular: 38.6%
Unclassified: 11.1%
Treatment Characteristics
Vitamin C started on the day of injury for 50 days in all three studies
500mg dose in two studies
200, 500, & 1500 mg in the remaining studies
Wrist fractures
Nonoperative: 85.1%
Operative: 14.9%
Meta-Analysis
The relative risk of CRPS-1 after a wrist fracture was not significantly diminished in the group given vitamin C at any dose
However, when isolated to the 500mg vitamin C versus the placebo, the risk was significantly reduced
In patients with wrist fractures, taking a vitamin C supplement of 500mg can prevent CRPS-1. This meta-analysis shows that the relative risk is 0.54 when receiving vitamin C when compared to the placebo group.
Eliminated all studies with the exception of three with unclear reasoning
Both positive studies came from the same lab
Attempts to repeat the findings resulted in a negative study
Heterogeneity
65% cited as nonsignificant, but is a significant amount
Limitations
References
Aïm F, Klouche S, Frison A, Bauer T, Hardy P. Efficacy of vitamin C in preventing complex regional pain syndrome after wrist fracture: A systematic review and meta-analysis. Orthop Traumatol Surg Res. 2017;103(3):465-470. doi:10.1016/j.otsr.2016.12.021
Ducharme J. Tips for Managing Complex Regional Pain Syndrome - Page 2 of 2. ACEP Now. https://www.acepnow.com/article/tips-for-managing-complex-regional-pain-syndrome/2/. Published April 1, 2019. Accessed September 11, 2021.
Goebel A, Bisla J, Carganillo R, et al. A randomised placebo-controlled Phase III multicentre trial: low-dose intravenous immunoglobulin treatment for long-standing complex regional pain syndrome (LIPS trial). Southampton (UK): NIHR Journals Library; 2017 Nov. (Efficacy and Mechanism Evaluation, No. 4.5.) Appendix 3, Research diagnostic criteria (the ‘Budapest Criteria’) for complex regional pain syndrome. Available from: https://www.ncbi.nlm.nih.gov/books/NBK464482/