No Higher Risk of CRPS After External Fixation of Distal Radial Fractures – Subgroup Analysis Under Randomised Vitamin C Prophylaxis§

Paul E. Zollinger*, 1, Robert W. Kreis2, Hub G. van der Meulen3, Maarten van der Elst4, Roelf S. Breederveld5, Wim E. Tuinebreijer5
1 Department of Orthopaedic Surgery, Ziekenhuis Rivierenland, Pres. Kennedylaan 1, 4002 WP Tiel, The Netherlands
2 Department of Burn Wounds and Department of Surgery, Red Cross Hospital, Beverwijk and Free University Hospital, Amsterdam, The Netherlands
3 Department of Surgery, Haga Hospital, The Hague, The Netherlands
4 Department of Surgery, Reinier de Graaf Group, Delft, The Netherlands
5 Department of Surgery, Red Cross Hospital, Beverwijk, The Netherlands

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© Zollinger et al.; Licensee Bentham Open.

open-access license: This is an open access article distributed under the terms of the Creative Commons Attribution License ( which permits unrestrictive use, distribution, and reproduction in any medium, provided the original work is properly cited.

* Address correspondence to this author at the Department of Orthopaedics, Ziekenhuis Rivierenland Tiel, P.O. Box 6024, 4000 HA Tiel, The Netherlands; Tel: +31344674217; Fax: +31344632903; E-mail: PE.
§ The participants in this study are three hospitals in the Netherlands: The surgical department of the Red Cross Hospital in Beverwijk, The orthopaedic and surgical department of the Haga Hospital (location Leyenburg) in the Hague and The orthopaedic and surgical department of the Reinier de Graaf Group in Delft.


Operative and conservative treatment of wrist fractures might lead to complex regional pain syndrome (CRPS) type I.

In our multicenter dose response study in which patients with distal radial fractures were randomly allocated to placebo or vitamin C in a daily dose of 200mg, 500mg or 1500mg during 50 days, an operated subgroup was analyzed.

48 (of 427) fractures) were operated (11.2%). Twenty-nine patients (60%) were treated with external fixation, 14 patients (29%) with K-wiring according to Kapandji and five patients (10%) with internal plate fixation. The 379 remaining patients were treated with a plaster.

In the operated group of patients who received vitamin C no CRPS (0/37) was seen in comparison with one case of CRPS (Kapandji technique) in the operated group who received placebo (1/11 = 9%, p=.23). There was no CRPS after external fixation.

In the conservatively treated group 17 cases of CRPS (17/379 = 4.5%) occurred in comparison with one in case of CRPS in the operated group (1/48 = 2.1%, p=.71).

External fixation doesn’t necessarily lead to a higher incidence of CRPS in distal radial fractures. Vitamin C may also play a role in this. This subgroup analysis in operated distal radial fractures showed no CRPS occurrence with vitamin C prophylaxis.

Keywords: Ascorbic acid, complex regional pain syndrome, external fixators, radius fractures, reflex sympathetic dystrophy, vitamin C.