SLR - August 2014 - Sarah Haller

Symptomatic Venous Thromboembolism Uncommon without Thromboprophylaxis After Isolated Lower-Limb Fracture: The Knee-to-Ankle Fracture (KAF) Cohort Study

Reference: Selby R, Geerts WH, Kreder HJ, Crowther MA, Kaus L, Sealey F. Symptomatic Venous Thromboembolism Uncommon without Thromboprophylaxis After Isolated Lower-Limb Fracture: The Knee-to-Ankle Fracture (KAF) Cohort Study.  J Bone Joint Surg Am. 2014 May 21; 96(10): e83.

Reviewed By: Sarah Haller PGY-1
Residency Program: Hoboken University Medical Center, Hoboken NJ

Podiatric Relevance: Fractures distal to the knee treated either conservatively or surgically are at higher risk for venous thromboembolism secondary to immobilization therapy. Currently, there are no current standards for prophylaxis in patients treated for isolated lower extremity fractures. This study goal was to evaluate and assess risks associated with higher incidence of deep venous thromboembolism or pulmonary embolism to determine if anticoagulation prophylaxis or mechanical prophylaxis was warranted.

Methods: A total of 1200 patients ranging in age from 16-93 years of age with a 60 percent female predominance were evaluated. Ninety-nine percent of all fracture patterns were unilateral ranging from fibular (39 percent), metatarsal (31 percent), phalangeal (12 percent), calcaneal, talar, and tarsal (10 percent), tibial (10 percent) and patellar (5 percent). Patients on aspirin or other antiplatelet therapy were permitted to continue use only with history of stroke or cardiac prophylaxis. The majority of patients (82 percent) were treated with cast or splint immobilization for six weeks. Suspected deep vein thrombosis were investigated with multiple imaging studies: Doppler ultrasonography, lung scanning or computed tomography pulmonary angiography.

Results: Of the 1200 patients, there were seven confirmed venous thromboembolic events, including two proximal deep vein thrombosis, three calf deep vein thrombosis and two pulmonary embolisms that were indicated with Doppler ultrasonography. In this study there were no deaths secondary to pulmonary embolism.

Conclusion: Routine anti-coagulation prophylaxis would not be beneficial or cost-effective for all patients that sustain lower extremity fractures that are immobilized for six weeks. In lower extremity fractures, the risk might outweigh the benefits of anti-coagulation therapy. With such a low incidence of venous thromboembolic events observed in this large cohort study of non-surgical treatment of closed lower extremity fractures, the authors recommend close follow up of these patients with education about potential symptoms that would alert them to seek appropriate medical attention. 

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