Original Report| Volume 15, ISSUE 1, P16-23, January 2014

Intense Pain Soon After Wrist Fracture Strongly Predicts Who Will Develop Complex Regional Pain Syndrome: Prospective Cohort Study

Published:November 21, 2013DOI:


      Complex regional pain syndrome (CRPS) is a distressing and difficult-to-treat complication of wrist fracture. Estimates of the incidence of CRPS after wrist fracture vary greatly. It is not currently possible to identify who will go on to develop CRPS after wrist fracture. In this prospective cohort study, a nearly consecutive sample of 1,549 patients presenting with wrist fracture to 1 of 3 hospital-based fracture clinics and managed nonsurgically was assessed within 1 week of fracture and followed up 4 months later. Established criteria were used to diagnose CRPS. The incidence of CRPS in the 4 months after wrist fracture was 3.8% (95% confidence interval = 2.9–4.8%). A prediction model based on 4 clinical assessments (pain, reaction time, dysynchiria, and swelling) discriminated well between patients who would and would not subsequently develop CRPS (c index .99). A simple assessment of pain intensity (0–10 numerical rating scale) provided nearly the same level of discrimination (c index .98). One in 26 patients develops CRPS within 4 months of nonsurgically managed wrist fracture. A pain score of ≥5 in the first week after fracture should be considered a “red flag” for CRPS.


      This study shows that excessive baseline pain in the week after wrist fracture greatly elevates the risk of developing CRPS. Clinicians can consider a rating of greater than 5/10 to the question “What is your average pain over the last 2 days?” to be a “red flag” for CRPS.

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        • Acerra N.E.
        • Moseley G.L.
        Dysynchiria: Watching the mirror image of the unaffected limb elicits pain on the affected side.
        Neurology. 2005; 65: 751-753
        • Atkins R.M.
        • Duckworth T.
        • Kanis J.A.
        Features of algodystrophy after Colles' fracture.
        J Bone Joint Surg Br. 1990; 72: 105-110
        • Austin P.C.
        Using the bootstrap to improve estimation and confidence intervals for regression coefficients selected using backwards variable elimination.
        Stat Med. 2008; 27: 3286-3300
        • Austin P.C.
        • Tu J.V.
        Bootstrap methods for developing predictive models.
        Am Stat. 2004; 58: 131-137
        • Bacorn R.
        • Kurtz J.
        Colles' fracture: A study of 2000 cases from the New York State Workmen's Compensation Board.
        J Bone Joint Surg. 1953; 35A: 643-658
        • Bruehl S.
        • Harden R.N.
        • Galer B.S.
        • Saltz S.
        • Bertram M.
        • Backonja M.
        • Gayles R.
        • Rudin N.
        • Bhugra M.K.
        • Stanton-Hicks M.
        External validation of IASP diagnostic criteria for complex regional pain syndrome and proposed research diagnostic criteria. International Association for the Study of Pain.
        Pain. 1999; 81: 147-154
        • Daly A.E.
        • Bialocerkowski A.E.
        Does evidence support physiotherapy management of adult Complex Regional Pain Syndrome Type One? A systematic review.
        Eur J Pain. 2009; 13: 339-353
        • de Mos M.
        • de Bruijn A.G.J.
        • Huygen F.J.P.M.
        • Dieleman J.P.
        • Stricker B.H.C.
        • Sturkenboom M.C.J.M.
        The incidence of complex regional pain syndrome: A population-based study.
        Pain. 2007; 129: 12-20
        • de Mos M.
        • Huygen F.
        • Dieleman J.P.
        • Koopman J.
        • Stricker B.H.C.
        • Sturkenboom M.
        Medical history and the onset of complex regional pain syndrome (CRPS).
        Pain. 2008; 139: 458-466
        • de Mos M.
        • Huygen F.J.P.M.
        • van der Hoeven-Borgman M.
        • Dieleman J.P.
        • Ch. Stricker B.H.
        • Sturkenboom M.C.J.M.
        Outcome of the complex regional pain syndrome.
        Clin J Pain. 2009; 25: 590-597
        • Demir S.E.
        • Ozaras N.
        • Karamehmetoglu S.S.
        • Karacan I.
        • Aytekin E.
        Risk factors for complex regional pain syndrome in patients with traumatic extremity injury.
        Ulusal Travma Ve Acil Cerrahi Derg. 2010; 16: 144-148
        • Dijkstra P.U.
        • Groothoff J.W.
        • ten Duis H.J.
        • Geertzen J.H.
        Incidence of complex regional pain syndrome type I after fractures of the distal radius.
        Eur J Pain. 2003; 7: 457-462
        • Frykman G.
        Fracture of the distal radius including sequelae—shoulder-hand-finger syndrome, disturbance in the distal radio-ulnar joint and impairment of nerve function. A clinical and experimental study.
        Acta Orthop Scand. 1967; : 103+
        • Grobbee D.
        • Hoes A.
        Clinical Epidemiology: Principles, Methods and Applications for Clinical Research.
        Jones & Bartlett, Sudbury, MA2009
        • Harrell F.
        • Lee K.
        • Mark D.
        Multivariate prognostic models: Issues in developing models, evaluating assumptions and adequacy, and measuring and reducing errors.
        Stat Med. 1996; 15: 361-387
        • Hosmer D.W.
        • Lemesbow S.
        Goodness of fit tests for the multiple logistic regression model.
        Commun Stat Theor Methods. 1980; 9: 1043-1069
        • Hove L.M.
        Nerve entrapment and reflex sympathetic dystrophy after fractures of the distal radius.
        Scand J Plast Reconstr Surg Hand Surg. 1995; 29: 53-58
        • Kemler M.A.
        • Furnee C.A.
        The impact of chronic pain on life in the household.
        J Pain Symptom Manage. 2002; 23: 433-441
        • Kenward M.
        • Carpenter J.
        Multiple imputation: Current perspectives.
        Stat Methods Med Res. 2007; 16: 199-218
        • Marinus J.
        • Moseley G.L.
        • Birklein F.
        • Baron R.
        • Maihofner C.
        • Kingery W.S.
        • van Hilten J.J.
        Clinical features and pathophysiology of complex regional pain syndrome—Current state of the art.
        Lancet Neurol. 2011; 10: 637-648
        • Merskey H.
        • Bogduk N.
        Classification of Chronic Pain.
        IASP Press, Seattle, WA1994
        • Moseley G.L.
        Why do people with complex regional pain syndrome take longer to recognize their affected hand?.
        Neurology. 2004; 62: 2182-2186
        • Perez R.S.
        • Zollinger P.E.
        • Dijkstra P.U.
        • Thomassen-Hilgersom I.L.
        • Zuurmond W.W.
        • Rosenbrand K.C.
        • Geertzen J.H.
        Evidence based guidelines for complex regional pain syndrome type 1.
        BMC Neurol. 2010; 10: 20
        • Sullivan M.J.L.
        • Bishop S.R.
        • Pivik J.
        The Pain Catastrophizing Scale: Development and validation.
        Psychol Assess. 1995; 7: 524-532
        • Sullivan M.J.L.
        • Thorn B.
        • Haythornthwaite J.A.
        • Keefe F.
        • Martin M.
        • Bradley L.A.
        • Lefebvre J.C.
        Theoretical perspectives on the relation between catastrophizing and pain.
        Clin J Pain. 2001; 17: 52-64
        • Thomson McBride A.R.
        • Barnett A.J.
        • Livingstone J.A.
        • Atkins R.M.
        Complex regional pain syndrome (type 1): A comparison of 2 diagnostic criteria methods.
        Clin J Pain. 2008; 24: 637-640
        • Zborowski M.
        Cultural components in responses to pain.
        J Soc Issues. 1952; 8: 16-30
        • 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?.
        J Bone Joint Surg Am. 2007; 89A: 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


        • Acerra N.E.
        • Moseley G.L.
        Dysynchiria: Watching the mirror image of the unaffected limb elicits pain on the affected side.
        Neurology. 2005; 65: 751-753
        • Kramer H.H.
        • Seddigh S.
        • Lorimer Moseley G.
        • Birklein F.
        Dysynchiria is not a common feature of neuropathic pain.
        Eur J Pain. 2008; 12: 128-131
        • Sullivan M.J.L.
        • Bishop S.R.
        • Pivik J.
        The Pain Catastrophizing Scale: Development and validation.
        Psychol Assess. 1995; 7: 524-532