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DVT prophylaxis unnecessary for lower leg fracture patients

Researchers found less than 1% incidence of venous thromboembolism among almost 1200 leg fracture patients.

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Routine use of anticoagulants is not necessary to prevent venous thromboembolism in patients with lower leg fractures, Canadian researchers have found.

Previous venography studies have suggested that up to 40% of such patients experience deep vein thrombosis (DVT), and surgeons often prescribe anticoagulants throughout the immobilization period. However, most DVT cases appear clinically silent when detected by venography, and their significance remains poorly understood. Thus, uncertainty remains on whether prevention recommendations should depend on venography findings, according to a press release announcing the study results.

Rita Selby, MD, MSc, an associate professor in the department of hematology at the University of Toronto, and colleagues prospectively evaluated the incidence of symptomatic venous thromboembolism (VTE) in patients with fractures below the knee.

The study included data for 1174 patients treated from August 2002 to June 2005 at five Ontario hospitals. These patients averaged 45 years of age, and women comprised 60% of the study population.

Of the 1174 patients who completed three months follow-up, only seven patients (0.6%) developed symptomatic VTE. This included two cases of proximal DVT, three cases of calf DVT and two cases of nonfatal pulmonary embolism (PE), according to the study.

All patients had been enrolled within 96 hours of injury. Fractures involved the fibula in about 39% of cases, metatarsal in 30%, phalanges in 12%, calcaneus, talus or tarsal in 10%, tibia in 10% and patella in 5%. Falls caused most fractures (56%), followed by vehicular accidents (25%), sports injuries (16%) and occupational injuries (3%). Treatment involved casting or bracing for an average of six weeks in 82% of cases and surgery in 7%, according to the study.

Researchers investigated any symptoms of DVT or PE in a standardized manner. No patients were permitted to use blood thinning agents during follow-up, although six patients (0.5%) received anticoagulants outside the study protocol.

“Based on our results, symptomatic VTE was so uncommon in patients with such fractures that routine use of anticoagulants to prevent blood clots ... is not warranted or cost effective,” Selby said in the press release.

“Additionally, we were unable to identify any high-risk subgroups ... that might be suitable for targeted prophylaxis,” she said.

The study highlights the discrepancy in VTE incidence between venography studies and studies using clinical endpoints, underscoring the need to reevaluate clinical trial methods evaluating VTE prevention, Selby added.

For more information:

• Selby R, Geerts WH, Crowther MA, et al. A prospective cohort study of the epidemiology of symptomatic venous thromboembolism (VTE) after isolated leg fractures distal to the knee without thromboprophylaxis. #583. Presented at the American Society of Hematology 47th Annual Meeting and Exposition. Dec. 10-13, 2005. Atlanta.