162 – Should routine VTE prophylaxis be administered to patients undergoing upper extremity immobilization, such as casting?

162 – Should routine VTE prophylaxis be administered to patients undergoing upper extremity immobilization, such as casting?

Kenneth A. Egol.

Response/Recommendation: While there are no official guidelines recommending routine venous thromboembolism (VTE) prophylaxis for patients undergoing upper extremity immobilization, the risk of upper extremity VTE is still present. Given that VTE prophylaxis for high-risk patients undergoing various lower limb or spinal orthopaedic procedures is recommended, VTE prophylaxis in high-risk patients undergoing upper extremity immobilization may be beneficial. However, evidence is inconclusive and further research must be done.

Strength of Recommendation: Limited.

Rationale: At this point in time there are no official guidelines recommending routine VTE prophylaxis for patients undergoing upper extremity immobilization. This immobilization can include a cast, splint, or other orthopaedic intervention for stability. VTE involves the formation of a blood clot within the venous system, often in the deep veins of the leg or pelvis1,2. Other terminology associated with a VTE may include a deep venous thrombosis (DVT) or pulmonary embolism (PE), with both being potentially dangerous complications resulting in elevated mortality. Risk factors for VTE include major surgery, trauma, malignancy, and immobilization3,4. Although less common than in the lower extremity, an estimated 1% to 4% of VTE involve the upper extremity5. Multiple case reports from orthopaedic literature discuss this potential for upper extremity VTE following orthopaedic injury6–8. Further morbidity or mortality may arise from these upper extremity VTE with 9% to 14% of these VTE progressing to a PE9. Therefore, it is important to recognize high-risk patients for upper extremity VTE and provide appropriate prophylaxis. “High-risk” patients include an elevated age, or presence of comorbidities including hypertension treated with medication, and wound infection as these have been shown to increase the risk of DVT10.

Despite the lack of evidence surrounding upper extremity VTE prophylaxis, there have been multiple studies focused on VTE prophylaxis in other orthopaedic procedures. These include hip and knee arthroplasty, as well as spinal surgery. The American Academy of Surgeons (AAOS) and the American College of Chest Physicians (ACCP) have created guidelines specifically covering prophylaxis following hip and knee arthroplasty11–13. Between these guidelines, there is no conclusive universal recommendation for which specific chemoprophylaxis to provide, the timeline of administration, and the scenarios for which chemoprophylaxis should be withheld. For example, patients undergoing knee arthroscopy with minimal risk factors are recommended to have no chemoprophylaxis. Alternative measures include early mobilization/ambulation, mechanical compression, transcutaneous nerve stimulation, and adequate hydration14–16. European guidelines demonstrating that hydration and early ambulation are especially promising for low-risk patients undergoing day surgeries17.

For specific instances of upper extremity VTE in patients with immobilization in a cast or splint as a risk factor, a case-control study highlighted a patient cohort of 10 individuals with plaster immobilization. Three out of ten patients demonstrated upper extremity VTE within 3-months of immobilization [odds ratio [OR] 7.6 (2.0-29.9)]18. Another case report demonstrated upper extremity VTE in a patient with distal humeral shaft fracture treated with a coaptation splint19. Four days post immobilization, the patient presented with increasing forearm pain and swelling. Ultrasound later confirmed the presence of a right brachial vein thrombus. This patient was not on any prophylaxis at the time, requiring a brief hospitalization and home-discharge on warfarin. It is important to note that inherent in these case reports is the individual variability seen when placing different types of immobilizations. This adds further uncertainty to guidelines when assessing the need for VTE prophylaxis. The 2018 published guidelines by the National Institute for Health and Care Excellence (NICE) stated that for upper limb orthopaedic surgery: 1) VTE prophylaxis is generally not needed if giving local or regional anesthetic for upper limb surgery. 2) VTE prophylaxis may be considered for people undergoing upper limb surgery if the person’s total time under general anesthesia is over 90 minutes or the operation will likely make the patient more difficult to mobilize themselves20.

Considering the known risk factor of immobilization with the development of VTE, the case reports found in orthopaedic literature, and the 2018 guidelines published by NICE, it is appropriate to recognize the possible need for VTE prophylaxis for upper extremity immobilization, especially in patients with predisposing comorbidities or other risk factors. Further research will need to be conducted to assess whether the type and duration of immobilization impacts the risk of VTE as well as which form of prophylaxis is best standard of care for each situation.

References:

1.         Phillippe HM. Overview of venous thromboembolism. Am J Manag Care. 2017;23(20 Suppl):S376-S382.

2.         Hillegass E, Puthoff M, Frese EM, et al. Role of Physical Therapists in the Management of Individuals at Risk for or Diagnosed With Venous Thromboembolism: Evidence-Based Clinical Practice Guideline. Phys Ther. 2016;96(2):143-166. doi:10.2522/ptj.20150264

3.         Anderson FA, Spencer FA. Risk factors for venous thromboembolism. Circulation. 2003;107(23 Suppl 1):I9-16. doi:10.1161/01.CIR.0000078469.07362.E6

4.         Beckman MG, Hooper WC, Critchley SE, Ortel TL. Venous thromboembolism: a public health concern. Am J Prev Med. 2010;38(4 Suppl):S495-501. doi:10.1016/j.amepre.2009.12.017

5.         Elman EE, Kahn SR. The post-thrombotic syndrome after upper extremity deep venous thrombosis in adults: a systematic review. Thromb Res. 2006;117(6):609-614. doi:10.1016/j.thromres.2005.05.029

6.         Creighton RA, Cole BJ. Upper extremity deep venous thrombosis after shoulder arthroscopy: a case report. J Shoulder Elbow Surg. 2007;16(1):e20-22. doi:10.1016/j.jse.2006.04.002

7.         Willis AA, Verma NN, Thornton SJ, Morrissey NJ, Warren RF. Upper-extremity deep-vein thrombosis after anterior shoulder dislocation and closed reduction. A case report. J Bone Joint Surg Am. 2005;87(9):2086-2090. doi:10.2106/JBJS.D.02135

8.         Adla DN, Ali A, Shahane SA. Upper-extremity deep-vein thrombosis following a clavicular fracture. Eur J Orthop Surg Traumatol Orthop Traumatol. 2004;14(3):177-179. doi:10.1007/s00590-004-0151-4

9.         Black MD, French GJ, Rasuli P, Bouchard AC. Upper extremity deep venous thrombosis. Underdiagnosed and potentially lethal. Chest. 1993;103(6):1887-1890. doi:10.1378/chest.103.6.1887

10.       Bokshan SL, DeFroda SF, Panarello NM, Owens BD. Risk Factors for Deep Vein Thrombosis or Pulmonary Embolus Following Anterior Cruciate Ligament Reconstruction. Orthop J Sports Med. 2018;6(6):2325967118781328. doi:10.1177/2325967118781328

11.       Mont MA, Jacobs JJ. AAOS clinical practice guideline: preventing venous thromboembolic disease in patients undergoing elective hip and knee arthroplasty. J Am Acad Orthop Surg. 2011;19(12):777-778. doi:10.5435/00124635-201112000-00008

12.       Falck-Ytter Y, Francis CW, Johanson NA, et al. Prevention of VTE in orthopedic surgery patients: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest. 2012;141(2 Suppl):e278S-e325S. doi:10.1378/chest.11-2404

13.       Jacobs JJ, Mont MA, Bozic KJ, et al. American Academy of Orthopaedic Surgeons clinical practice guideline on: preventing venous thromboembolic disease in patients undergoing elective hip and knee arthroplasty. J Bone Joint Surg Am. 2012;94(8):746-747. doi:10.2106/JBJS.9408.ebo746

14.       Izumi M, Ikeuchi M, Aso K, et al. Less deep vein thrombosis due to transcutaneous fibular nerve stimulation in total knee arthroplasty: a randomized controlled trial. Knee Surg Sports Traumatol Arthrosc Off J ESSKA. 2015;23(11):3317-3323. doi:10.1007/s00167-014-3141-z

15.       Lei Y-T, Xie J-W, Huang Q, Huang W, Pei F-X. Benefits of early ambulation within 24 h after total knee arthroplasty: a multicenter retrospective cohort study in China. Mil Med Res. 2021;8(1):17. doi:10.1186/s40779-021-00310-x

16.       Fawi HMT, Saba K, Cunningham A, et al. Venous thromboembolism in adult elective spinal surgery: a tertiary centre review of 2181 patients. Bone Jt J. 2017;99-B(9):1204-1209. doi:10.1302/0301-620X.99B9.BJJ-2016-1193.R2

17.       Venclauskas L, Llau JV, Jenny J-Y, Kjaersgaard-Andersen P, Jans Ø, ESA VTE Guidelines Task Force. European guidelines on perioperative venous thromboembolism prophylaxis: Day surgery and fast-track surgery. Eur J Anaesthesiol. 2018;35(2):134-138. doi:10.1097/EJA.0000000000000706

18.       Blom JW, Doggen CJM, Osanto S, Rosendaal FR. Old and new risk factors for upper extremity deep venous thrombosis. J Thromb Haemost JTH. 2005;3(11):2471-2478. doi:10.1111/j.1538-7836.2005.01625.x

19.       Sawyer GA, Hayda R. Upper-extremity deep venous thrombosis following humeral shaft fracture. Orthopedics. 2011;34(2):141. doi:10.3928/01477447-20101221-27

20.       National Guideline Centre (UK). Venous Thromboembolism in over 16s: Reducing the Risk of Hospital-Acquired Deep Vein Thrombosis or Pulmonary Embolism. National Institute for Health and Care Excellence (UK); 2018. Accessed September 27, 2021. http://www.ncbi.nlm.nih.gov/books/NBK493720/

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