Graham S. Goh, John J. Corvi, Robert F. Murphy.
Response/Recommendation: Many risk factors for venous thromboembolism (VTE) in pediatric orthopaedic patients are similar to those in adults. These include older age (adolescents), trauma, malignancy, certain infections, clotting disorders, and a personal or family history of VTE. However, certain VTE risk factors reported in adult literature (e.g., smoking) may be less prevalent in children, and vice versa (e.g., congenital thrombophilia).
Strength of Recommendation: Moderate.
Rationale: VTE is a common complication in adults undergoing orthopaedic surgery, and the risk factors for this condition are well established. In contrast, VTE is extremely rare in pediatric orthopaedic patients1. The incidence of VTE has been reported at 0.0515% for pediatric patients admitted following elective orthopaedic procedures2. The incidence rises to 0.10% when non-elective procedures are included3, and peaks at 0.68% in trauma patients4,5.
Epidemiologic data has demonstrated that the incidence of pediatric VTE is bimodal, with the highest incidence rates in infants and adolescents6. Pediatric patient populations with certain conditions are at an increased risk for VTE. These conditions include congenital heart disease, nephrotic syndrome, prior splenectomy in patients with hemolytic anemia, colectomy in patients with inflammatory bowel disease, congenital thrombophilia and other genetic or metabolic diseases7. Catheter-related thrombosis is the single most common cause of pediatric VTE8–10. Central venous catheters (CVC) may directly damage the vessel wall, increase blood flow turbulence, introduce substances that damage endothelial cells, and contain thrombogenic materials.
Due to the complex pathophysiology of pediatric patients, pediatric orthopaedic patients have different risk factors for VTE compared to their non-orthopaedic counterparts11,12. Currently, the literature suggests that the most common risk factors for VTE in pediatric orthopaedic patients are adolescent age, trauma, infection, cancer, clotting disorders, and a personal or family history of VTE9,11,13.
Pediatric trauma patients are an identifiable subgroup that is at highest risk of VTE14. However, the risk of VTE is not uniform across age groups, with most cases occurring in children aged 10 – 15 years (0.1%). In one study, Guzman et al.4, found that younger pediatric trauma patients (i.e., under 10 years) had a much lower risk of VTE compared to adolescents aged 13 – 15. Moreover, older adolescent patients (> 16 years) physiologically resembled adults and had similar VTE frequencies to the adult population4,8,11,15–18.
Another specific pediatric orthopaedic population at increased risk of VTE is children with musculoskeletal infections such as osteomyelitis or septic arthritis, especially if the infecting organism is Staphylococcus aureus9,19–23. The severity and duration of elevation in C-reactive protein (CRP) may predict the development of VTE, with every 20 mg/L increase in peak CRP associated with a 29% increase in risk of thrombosis24.
In conclusion, there is a paucity of high-quality data on the risk factors for VTE in pediatric orthopaedic patients. Risk factors for VTE in pediatric orthopaedic patients are largely similar to those in adults when the same comorbid conditions are considered. Further studies are needed to develop risk-stratification protocols specific for pediatric orthopaedic patients in order to determine which subgroup of patients may benefit from VTE prophylaxis.
1. Rohrer MJ, Cutler BS, MacDougall E, Herrmann JB, Anderson FA, Wheeler HB. A prospective study of the incidence of deep venous thrombosis in hospitalized children. Journal of Vascular Surgery. 1996;24(1):46-50. doi:10.1016/S0741-5214(96)70143-X
2. Georgopoulos G, Hotchkiss MS, McNair B, Siparsky G, Carry PM, Miller NH. Incidence of Deep Vein Thrombosis and Pulmonary Embolism in the Elective Pediatric Orthopaedic Patient. Journal of Pediatric Orthopaedics. 2016;36(1):101-109. doi:10.1097/BPO.0000000000000391
3. Baker D, Sherrod B, McGwin G, Ponce B, Gilbert S. Complications and 30-day Outcomes Associated With Venous Thromboembolism in the Pediatric Orthopaedic Surgical Population: Journal of the American Academy of Orthopaedic Surgeons. 2016;24(3):196-206. doi:10.5435/JAAOS-D-15-00481
4. Guzman D, Sabharwal S, Zhao C, Sabharwal S. Venous thromboembolism among pediatric orthopedic trauma patients: a database analysis. Journal of Pediatric Orthopaedics B. 2018;27(2):93-98. doi:10.1097/BPB.0000000000000424
5. Murphy RF, Naqvi M, Miller PE, Feldman L, Shore BJ. Pediatric orthopaedic lower extremity trauma and venous thromboembolism. J Child Orthop. 2015;9(5):381-384. doi:10.1007/s11832-015-0697-1
6. Mahajerin A, Croteau SE. Epidemiology and Risk Assessment of Pediatric Venous Thromboembolism. Front Pediatr. 2017;5:68. doi:10.3389/fped.2017.00068
7. Gerotziafas GT. Risk factors for venous thromboembolism in children. Int Angiol. 2004;23(3):195-205.
8. Allen CJ, Murray CR, Meizoso JP, et al. Risk factors for venous thromboembolism after pediatric trauma. Journal of Pediatric Surgery. 2016;51(1):168-171. doi:10.1016/j.jpedsurg.2015.10.033
9. Kim SJ, Sabharwal S. Risk factors for venous thromboembolism in hospitalized children and adolescents: a systemic review and pooled analysis. Journal of Pediatric Orthopaedics B. 2014;23(4):389-393. doi:10.1097/BPB.0000000000000053
10. Revel-Vilk S, Chan A, Bauman M, Massicotte P. Prothrombotic conditions in an unselected cohort of children with venous thromboembolic disease1. J Thromb Haemost. 2003;1(5):915-921. doi:10.1046/j.1538-7836.2003.00158.x
11. Samineni AV, Sanborn R, Shea J, et al. Pediatric Venous Thromboembolism: Different Rates of Incidence, Anatomic Locations, and Risk Factors Between Orthopaedic and Nonorthopaedic Related Patients. Journal of Pediatric Orthopaedics. 2021;41(6):379-384. doi:10.1097/BPO.0000000000001810
12. Spentzouris G, Scriven RJ, Lee TK, Labropoulos N. Pediatric venous thromboembolism in relation to adults. Journal of Vascular Surgery. 2012;55(6):1785-1793. doi:10.1016/j.jvs.2011.07.047
13. Shore BJ, Flaugh R, Shannon BA, Curran P, Hogue G. Preoperative Considerations for Teenagers Undergoing Orthopaedic Surgery: VTE Prevention, Mental Health Assessment, Vaping, and Drug Addiction. Journal of Pediatric Orthopaedics. 2021;41(Suppl 1):S64-S69. doi:10.1097/BPO.0000000000001764
14. Vavilala MS, Nathens AB, Jurkovich GJ, Mackenzie E, Rivara FP. Risk Factors for Venous Thromboembolism in Pediatric Trauma. The Journal of Trauma: Injury, Infection, and Critical Care. 2002;52(5):922-927. doi:10.1097/00005373-200205000-00017
15. Vu LT, Nobuhara KK, Lee H, Farmer DL. Determination of risk factors for deep venous thrombosis in hospitalized children. Journal of Pediatric Surgery. 2008;43(6):1095-1099. doi:10.1016/j.jpedsurg.2008.02.036
16. Sabharwal S, Zhao C, Passanante M. Venous Thromboembolism in Children: Details of 46 Cases Based on a Follow-up Survey of POSNA Members. J Pediatr Orthop. 2013;33(7):7.
17. Dhaliwal J. Venous Thromboembolism after Trauma: When Do Children Become Adults? The Journal of Emergency Medicine. 2014;46(6):874-875. doi:10.1016/j.jemermed.2014.04.003
18. Padhye K, El-Hawary R, Price V, Stevens S, Branchford B, Kulkarni K. Development of a perioperative venous thromboembolism prophylaxis algorithm for pediatric orthopedic surgical patients. Pediatric Hematology and Oncology. 2020;37(2):109-118. doi:10.1080/08880018.2019.1695030
19. Letts M, Lalonde F, Davidson D, Hosking M, Halton J. Atrial and Venous Thrombosis Secondary to Septic Arthritis of the Sacroiliac Joint in a Child with Hereditary Protein C Deficiency. Journal of Pediatric Orthopaedics. 1999;19(2):156-160. Accessed July 15, 2021. http://journals.lww.com/pedorthopaedics/Fulltext/1999/03000/Atrial_and_Venous_Thrombosis_Secondary_to_Septic.4.aspx
20. Walsh S, Phillips F. Deep Vein Thrombosis Associated With Pediatric Musculoskeletal Sepsis: Journal of Pediatric Orthopaedics. 2002;22(3):329-332. doi:10.1097/01241398-200205000-00011
21. Crary SE, Buchanan GR, Drake CE, Journeycake JM. Venous thrombosis and thromboembolism in children with osteomyelitis. The Journal of Pediatrics. 2006;149(4):537-541. doi:10.1016/j.jpeds.2006.06.067
22. Vander Have KL, Karmazyn B, Verma M, et al. Community-associated Methicillin-resistant Staphylococcus aureus in Acute Musculoskeletal Infection in Children: A Game Changer. Journal of Pediatric Orthopaedics. 2009;29(8):927-931. doi:10.1097/BPO.0b013e3181bd1e0c
23. Ligon JA, Journeycake JM, Josephs SC, Tareen NG, Lindsay EA, Copley LAB. Differentiation of Deep Venous Thrombosis Among Children With or Without Osteomyelitis. Journal of Pediatric Orthopaedics. 2018;38(10):e597-e603. doi:10.1097/BPO.0000000000001240
24. Amaro E, Marvi TK, Posey SL, et al. C-Reactive Protein Predicts Risk of Venous Thromboembolism in Pediatric Musculoskeletal Infection. Journal of Pediatric Orthopaedics. 2019;39(1):e62-e67. doi:10.1097/BPO.0000000000001256