DVT with ankle fractures: Is thromboprophylaxis

warranted?

Sunit Patil

Jamshid Gandhi

Ian Curzon

Anthony Hui

James Cook University Hospital, Middlesbrough

Background

Thromboprophylaxis for patients in a plaster cast is a standard of care in many European countriesChest (2004), 126:338-400

Incidence of DVT in patients in a plaster - about 20%

Background

Most studies so far have clubbed together patients with soft tissue injuries and fractures

Incidence of DVT is higher in patients with a fracture as opposed to soft tissue injury

Archives of Internal Medicine, 2002

Background

Incidence of DVT in patients with ankle fractures : unknown

Research Question

What is the incidence of DVT in patients with ankle fractures treated in a below knee plaster cast?

Methods

Prospective study

R&D and Ethical committee approval

Consecutive patients with ankle fractures treated at JCUH

Methods

Patients were identified from fracture clinic

Exclusion criteria: Previous DVT Patients already on thromboprophylaxis Patients treated with methods other than plaster Patients requiring surgery

Methods

At 6/52: Cast removal

Clinical assessment

Colour duplex ultrasound scan

Ultrasound Colour duplex ultrasound has a sensitivity of 96% and negative

predictive value of 99%Journal of thrombosis and haemostasis, 2006

Doppler ultrasound is the most universally accepted diagnostic test for lower extremity DVTACCP guidelines, 2004

Ultrasound

Scans were performed by one of the two experienced musculoskeletal ultrasound technicians

Philips IU22 duplex colour doppler ultrasound

Above knee DVT

Below knee DVT

Repeat scan at 1/52

Anti-coagulate

Treated as per consultant

Protocol for patients with DVT

Results 112 patients

8 declined to participate

3 required ORIF

1 was started on prophylactic LMWH by geriatrician

100 patients

Results Males: 51 Females: 49

Mean age: 43 years (16-79)

Mean BMI: 28 (18-51)

Smokers: 29

Mean duration of plaster cast: 6/52 (3-7)

Types of fractures

Weber A: 19

Weber B: 69

Weber C: 1

Medial malleolus: 9

Tillaux fracture: 2

Weight bearing status

Full weight bearing: 72

Partial weight bearing: 9

Non weight bearing:19

DVT

Superficial femoral vein: 1

Popliteal vein: 1

Posterior tibial vein + peroneal vein: 1

Peroneal vein: 2

DVT

All 5 were asymptomatic and had no clinical signs of DVT

All 5 were FWB during the period of immobilisation

DVTAge, Sex Predisposing factors

67, F None

53, M BMI=31.6, smoker

18, F BMI=28.3, smoker

69, F BMI=37.3

44, M BMI=28.4, smoker

Results

None of the DVTs propagated on a scan done a week later

None developed symptoms or signs of PE

Discussion

Annual incidence of DVT in the western population is 0.1%Silverstein et al; Archives of Internal Medicine, 1998.

Cumulative probability of venous thromboembolism by the age of 50 is 0.5% and by 80 is 3.8%.Hansson et al; Archives of Internal Medicine, 1997.

Discussion

DVT following THR/TKR: 40-80%

Clinical PE: 4-10%

Fatal PE: 0.5-2%

Source: Geerts et al, Chest 2004

Discussion

Our findings suggest a 5% incidence of DVT

95% confident Overall incidence of DVT is <9% Incidence of above knee DVT is <5%

Discussion

Author Patients included Incidence of DVT

Kujath et al, 1993

n=127

Lower limb injuries 16.5%

Kock et al, 1996

n=163

Lower limb injuries 4.3%

Jorgensen et al, 2002

n=106

Lower limb injuries 20%

Lassen et al, 2002

n=187

Lower limb injuries; included post-op as well

19%

Prophylaxis in UK

Thromboprophylaxis for ankle # % of hospitals surveyed

All patients 8.6 (n=6)

Only if pt was admitted 17.2 (n=12)

Only for high risk patients 5.7 (n=4)

No prophylaxis 62.8 (n=44)

Batra et al; Injury, 2006

Conclusion

Incidence of DVT following ankle fractures is 5%

Routine thromboprophylaxis is not justified

If it ain’t broke, don’t fix it!

Acknowledgment

We would like to thank the entire staff of the Orthopaedic Department, JCUH, for their support

Special thanks to Alison Gamble, Chris Cummins (ultrasound technicians) and Dr. R Bellamy

This project was funded by the Orthopaedic Department, James Cook University Hospital, Middlesbrough