Jacob E. Tulipan, Pedro Beredjiklian.

Response/recommendation: Routine venous thromboembolism (VTE) prophylaxis is not required for patients undergoing wrist surgery.  It should be considered in patients with strong family history of VTE or patients who are unable to ambulate perioperatively.

Strength of Recommendation: Limited.

Rationale: There are limited data regarding the rate of VTE following surgical procedures on the wrist.  Multiple studies evaluating overall complication rates following surgical procedures on the wrist report no VTE complications.  A meta-analysis by Stone et al., evaluating 3,628 patients who had anticoagulant or antiplatelet therapy continued or withheld for hand and wrist surgery demonstrated no VTE in either group, although the overall quality of evidence was low¹.  A review by Hastie et al., of 3,357 consecutive upper extremity surgeries at a single hospital from 2009–2012 found only a single VTE, which was a case of bilateral pulmonary embolism (PE) following carpal tunnel release in 77-year-old female with multiple DVT in the past².  A study by Ahsan et al., evaluated a total of 11,002 wrist arthroscopies and also reported no VTE³.  Similarly, a review by Greene et al., found no occurrences of VTE following elbow or wrist arthroscopy⁴.

There have been isolated case reports of VTE following bilateral upper extremity surgery.  Igeta et al., reported PE in an 80-year-old woman following fixation of bilateral open distal radius fractures, in the setting of immobility for 9 days following admission⁵.  Kim et al., reported PE following bilateral carpal tunnel release in a patient with a history of prior PE, for which she was on warfarin.  Of note, the warfarin had been discontinued for the surgery⁶.  Watanabe et al., reported on two cases of PE following upper extremity surgery– one following a bilateral distal radius fracture in a patient who was on bed rest for 4 days prior to surgery, and one involving the subclavian vein in a patient with an extremity immobilized for a groin flap⁷.

In patients with no major risk factors and no prolonged immobilization, routine VTE prophylaxis is not required for wrist surgery.  In patients with risk factors for VTE, including prolonged immobilization, VTE prophylaxis should be considered.

References:

1.         Stone MJ, Wilks DJ, Wade RG. Hand and wrist surgery on anticoagulants and antiplatelets: A systematic review and meta-analysis. J Plast Reconstr Aesthet Surg. 2020;73(8):1413-1423. doi:10.1016/j.bjps.2020.05.017

2.         Hastie GR, Pederson A, Redfern D. Venous thromboembolism incidence in upper limb orthopedic surgery: do these procedures increase venous thromboembolism risk? J Shoulder Elbow Surg. 2014;23(10):1481-1484. doi:10.1016/j.jse.2014.01.044

3.         Ahsan ZS, Yao J. Complications of Wrist and Hand Arthroscopy. Hand Clin. 2017;33(4):831-838. doi:10.1016/j.hcl.2017.07.008

4.         Greene JW, Deshmukh AJ, Cushner FD. Thromboembolic complications in arthroscopic surgery. Sports Med Arthrosc Rev. 2013;21(2):69-74. doi:10.1097/JSA.0b013e31828a7e76

5.         Igeta Y, Naito K, Sugiyama Y, Kaneko K, Obayashi O. Pulmonary thromboembolism after operation for bilateral open distal radius fractures: a case report. BMC Res Notes. 2014;7:36. doi:10.1186/1756-0500-7-36

6.         Kim JD, Kim JT, Gan AWT, Youn S, Kim YH. Pulmonary artery re-thrombosis following interruption of anti-thrombotic therapy for bilateral carpal tunnel release surgery: an update of current protocols. J Plast Reconstr Aesthet Surg. 2013;66(7):999-1002. doi:10.1016/j.bjps.2012.11.029

7.         Watanabe M, Hara K, Moriya K, Miura K. Pulmonary embolism after the operation of the upper extremity. Report of 2 cases. Kossetsu. 2012;34:409-412.