Richard L Donovan, Antoon van Raebroeckx, Michael R. Whitehouse.
Response/Recommendation: No studies have directly answered the question of whether immobilization of the upper extremity influences the venous thromboembolism (VTE) prophylaxis protocol. There is insufficient evidence to support any alteration in VTE prophylaxis protocol based on the need for immobilization of the upper extremity.
Strength of Recommendation: Limited.
Rationale: The Guidelines in Emergency Medicine Network (GEMNet) posed a similar question in 2013, asking “in patients with isolated upper extremity injury, does the use of temporary immobilization via plaster cast/sling increase the risk of subsequent venous thromboembolic events during short-term follow-up?”1. Only four papers met their inclusion criteria2–5, of which three were retrospective cohort studies and one was a case-control study. All four studies were small and none were designed to directly test the association between temporary upper extremity immobilization and VTE or associated prophylaxis protocols. They determined from this limited evidence that there was no evidence to suggest a significant risk of VTE in ambulatory patients with temporary upper extremity immobilization.
In the United Kingdom, the 2018 National Institute for Health and Care Excellence (NICE) guidelines for reducing the risk of hospital-acquired VTE makes two recommendations. First, that VTE prophylaxis is generally not required if upper limb surgery is taking place under local or regional anaesthesia; and second, that VTE prophylaxis should be considered if the duration of upper limb surgery under general anaesthesia will exceed 90 minutes or if the operation will make it more difficult for the patient to mobilize afterwards6,7. Again, the recommendation does not include immobilization of the upper limb as a factor in the decision-making process.
A 2013 consensus statement from Italy provided limited recommendations for VTE prophylaxis in patients undergoing upper limb surgery. They recognized that VTE is a rare complication of upper extremity surgery and non-joint replacement surgery of the shoulder, but recommended pharmacological prophylaxis with low-molecular-weight heparin (LMWH) in patients undergoing shoulder joint replacement surgery. They also suggested pharmacological prophylaxis with LMWH should be considered in non-prosthetic surgery patients who have risk factors for VTE for a minimum of seven days and prolonged if a patient will be confined to bed for an extended period. Similar recommendations were made for shoulder arthroscopy. In circumstances of upper limb fracture, VTE prophylaxis was recommended only in circumstances of bed confinement, poorly mobile patients with VTE risk factors, and crush injuries – with prophylaxis for 30 days or until mobility out of bed is restored. For elbow and wrist arthroscopy, VTE prophylaxis was not advised, but they recognized that this is an area that has not been studied8.
1. Roberts C, Horner D, Coleman G, et al. Guidelines in Emergency Medicine Network (GEMNet): guideline for the use of thromboprophylaxis in ambulatory trauma patients requiring temporary limb immobilisation. Emerg Med J. 2013;30(11):968-982. doi:10.1136/emermed-2013-203134
2. Blom JW, Doggen CJM, Osanto S, Rosendaal FR. Old and new risk factors for upper extremity deep venous thrombosis. J Thromb Haemost. 2005;3(11):2471-2478. doi:10.1111/j.1538-7836.2005.01625.x
3. Martinelli I, Battaglioli T, Bucciarelli P, Passamonti SM, Mannucci PM. Risk factors and recurrence rate of primary deep vein thrombosis of the upper extremities. Circulation. 2004;110(5):566-570. doi:10.1161/01.CIR.0000137123.55051.9B
4. Marinella MA, Kathula SK, Markert RJ. Spectrum of upper-extremity deep venous thrombosis in a community teaching hospital. Heart Lung. 2000;29(2):113-117.
5. Spencer FA, Emery C, Lessard D, Goldberg RJ, Worcester Venous Thromboembolism Study. Upper extremity deep vein thrombosis: a community-based perspective. Am J Med. 2007;120(8):678-684. doi:10.1016/j.amjmed.2006.06.046
6. 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/
7. Bircher A, Chowdhury A. Current DVT prophylaxis: a review. Orthopaedics and Trauma. 2020;34(3):161-167. doi:10.1016/j.mporth.2020.03.010
8. Randelli F, Romanini E, Biggi F, et al. II Italian intersociety consensus statement on antithrombotic prophylaxis in orthopaedics and traumatology: arthroscopy, traumatology, leg immobilization, minor orthopaedic procedures and spine surgery. J Orthop Traumatol. 2013;14(1):1-13. doi:10.1007/s10195-012-0214-y