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Extended thromboprophylaxis for lower-limb injury, cast immobilization unjustified
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BIRMINGHAM, England — Data collected at the Colchester Hospital University NHS Foundation Trust revealed a low incidence of thromboembolic events in patients with lower-limb fractures or soft-tissue injuries treated with plaster, which led researchers to conclude that extended thromboprophylaxis for these patients is not justified in the absence of significant preexisting risk factors.
“There is not really sufficient evidence to draw firm conclusions regarding this matter for lower-limb injuries,” Aditya Prinja, said at the British Orthopaedic Association Congress, here, where he presented the data.
“Even the National Institute for Health and Care Excellence guidelines — most recently from January 2010 on this topic — recommend further trials to establish which patients should receive extended prophylaxis due to the wide-ranging data,” Prinja said.
Investigations for DVT or PE
Prinja and colleagues conducted a retrospective study to determine the incidence of thromboembolic events in patients with lower-limb injuries. They used hospital coding data to identify patients who presented to the Colchester Hospital center between January 2003 and May 2012 with lower limb fractures. They excluding patients with hip and femoral shaft fractures and those with soft tissue injuries of the lower limb treated in plaster.
In all, the researchers identified 2,862 such patients and found that 52 of them had been investigated within a 90-day period for deep vein thrombosis (DVT) or pulmonary embolism (PE). Of these 52 patients, 13 patients, including six men and seven women with a mean age of 59 years, were positive for a thromboembolic event, yielding a total venous thromboembolism (VTE) incidence rate of 0.45%. Six patients had a PE and seven had a DVT. One of these events was fatal.
Injuries that the patients had included six ankle, three tibial plateau, one calcaneal and two tibial diaphyseal fractures, as well as one ankle sprain. All patients were non-weight bearing for at least 4 weeks and were immobilized in a cast for at least 6 weeks. The maximum length of time for non-weight bearing and immobilization among those studied was 24 weeks. None of the patients had received extended prophylaxis.
Most patients have risk factors
“Looking at the patients in slightly more detail, the most interesting thing that we found is the presence of risk factors in a large majority of these patients,” Prinja said. “The incidence of 0.45% VTE events in lower limb trauma is low, and on the basis of these findings, I would say there is no justification for VTE thromboprophylaxis for patients with lower-limb fractures. We would, however, add the caveat that if patients have significant pre-existing risk factors for VTE, extended prophylaxis should be considered.”
Prinja acknowledged in his presentation that there were some limitations to the study. This included the study’s retrospective nature, which could have led to lost patients who were followed up at different hospitals or who presented with their VTE event elsewhere. – by Tina DiMarcantonio
- Reference:
- Prinja A. Paper #219. Presented at: British Orthopaedic Association Congress; Oct. 1-4, 2013; Birmingham, England.
- For more information:
- Aditya Prinja, can be reached at Colchester Hospital University NHS Foundation Trust, Turner Road, Colchester, Essex CO4 5JL, UK; email: a.prinja@cantab.net.
Disclosure: Prinja has no relevant financial disclosures.