Abtin Alvand, Raja Bhaskara Rajasekaran, Marc Swiontkowski.
Response/Recommendation: Routine venous thromboembolism (VTE) prophylaxis is not routinely needed in patients with a single lower extremity (LE) fracture who do not require surgery. The need for VTE prophylaxis in patients with isolated LE fracture is restricted to high-risk individuals with significant medical comorbidities, severely limited activity or other coagulopathic risk factors.
Strength of Recommendation: Moderate.
Rationale: Fractures of the LE are common, with an annual incidence of approximately 17% to 22%1,2. The incidence of these fractures is increasing3, and a significant proportion of these fractures are managed non-operatively, most commonly with cast immobilization4,5. The incidence of VTE in patients with isolated LE fracture who do not require surgery is low, with reported rates of 0.1% to 4%, leading most to believe that there is no need for routine thromboprophylaxis in this patient population6,7,8,9.
An interesting finding amongst patients with LE injuries is that compared to foot and ankle fractures, acute achilles tendon ruptures have a relatively greater incidence of developing VTE7,10, probably due to dysfunction of the calf muscle pump. Contrary to popular belief, active ankle and toe movements and compression stockings did not reduce VTE incidence and are not viable strategies for preventing VTE11,12. Existing literature remains inconclusive with regards to the need for thromboprophylaxis for patients receiving this mode of management.
The American College of Chest Physicians (ACCP) guidelines does not recommend any prophylaxis for isolated LE fractures requiring immobilization13. Jameson et al., after retrospectively analyzing 14,777 adults over a 54-month period, stated that isolated ankle fractures not requiring surgery is not an indication for routine VTE prophylaxis14. In addition, Selby et al., found routine prophylaxis to be less favorable for these patients15 following analysis based on their prospective multicenter study. In contrast, other studies have demonstrated that prophylaxis significantly reduces VTE incidence and related events in patients with isolated LE fractures treated with immobilization16-20. Assessment of risk factors and developing clinical risk assessment models predicting VTE in these patients would therefore improve the evidence gap in this domain.
Few studies have sought to assess risk factors and patients at risk for developing VTE following non-surgical treatment for isolated LE fractures21-23. Age > 70 years, limited mobility in and out of hospital21, immobilization22,23, previous history of VTE, high body mass index (BMI), oral contraceptive pill intake, and air-travel23 have been reported as risk factors, particularly when two or more are present. The thrombosis risk prediction following cast immobilization (L-TRiP) score24 and the trauma, immobilization and patients’ characteristics (TIP) score25 are useful tools for accurately stratifying patients into risk categories in order to guide thromboprophylaxis. The evidence base for the optimal choice of pharmacological prophylaxis in these patients varies with low-molecular-weight heparin (LMWH)19,20 and oral anticoagulants (such as nadroparin or fondaparinux or rivaroxaban)16,26 being shown to be effective in preventing VTE and related events.
Based on available literature, administration of routine VTE prophylaxis for patients with isolated LE injuries, even if immobilized, does not seem to be supported. However, VTE prophylaxis in the forms of mechanical or chemical treatment may need to be considered for high-risk patients (see risk stratification) with isolated LE injury.
References:
1) Amin S, Achenbach SJ, Atkinson EJ, Khosla S, Melton LJ 3rd. Trends in fracture incidence: a population-based study over 20 years. J Bone Miner Res. 2014;29(3):581-589. doi:10.1002/jbmr.2072
2) Lambers K, Ootes D, Ring D. Incidence of patients with lower extremity injuries presenting to US emergency departments by anatomic region, disease category, and age. Clin Orthop Relat Res. 2012;470(1):284-290. doi:10.1007/s11999-011-1982-z
3) Hemmann P, Friederich M, Körner D, Klopfer T, Bahrs C. Changing epidemiology of lower extremity fractures in adults over a 15-year period – a National Hospital Discharge Registry study. BMC Musculoskelet Disord. 2021;22(1):456. Published 2021 May 19. doi:10.1186/s12891-021-04291-9
4) Jameson SS, Rankin KS, Desira NL, et al. Pulmonary embolism following ankle fractures treated without an operation – an analysis using National Health Service data. Injury. 2014;45(8):1256-1261. doi:10.1016/j.injury.2014.05.009
5) Jain N, Symes T, Doorgakant A, Dawson M. Clinical audit of the management of stable ankle fractures. Ann R Coll Surg Engl. 2008;90(6):483-487. doi:10.1308/003588408X301145
6) Jameson SS, Augustine A, James P, et al. Venous thromboembolic events following foot and ankle surgery in the English National Health Service. J Bone Joint Surg Br. 2011;93(4):490-497. doi:10.1302/0301-620X.93B4.25731
7) Blanco JA, Slater G, Mangwani J. A Prospective Cohort Study of Symptomatic Venous Thromboembolic Events in Foot and Ankle Trauma: The Need for Stratification in Thromboprophylaxis?. J Foot Ankle Surg. 2018;57(3):484-488. doi:10.1053/j.jfas.2017.10.036
8) Iqbal HJ, Dahab R, Barnes S. UK national survey of venous thromboembolism prophylaxis in ankle fracture patients treated with plaster casts. Foot Ankle Surg. 2012;18(3):157-159. doi:10.1016/j.fas.2011.05.004
9) 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
10) Braithwaite I, De Ruyter B, Semprini A, et al. Cohort feasibility study of an intermittent pneumatic compression device within a below-knee cast for the prevention of venous thromboembolism. BMJ Open. 2016;6(10):e012764. Published 2016 Oct 4. doi:10.1136/bmjopen-2016-012764
11) Hickey BA, Cleves A, Alikhan R, Pugh N, Nokes L, Perera A. The effect of active toe movement (AToM) on calf pump function and deep vein thrombosis in patients with acute foot and ankle trauma treated with cast – A prospective randomized study. Foot Ankle Surg. 2017;23(3):183-188. doi:10.1016/j.fas.2016.04.007
12) Sultan MJ, Zhing T, Morris J, Kurdy N, McCollum CN. Compression stockings in the management of fractures of the ankle: a randomised controlled trial. Bone Joint J. 2014;96-B(8):1062-1069. doi:10.1302/0301-620X.96B8.32941
13) 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
14) Jameson SS, Rankin KS, Desira NL, et al. Pulmonary embolism following ankle fractures treated without an operation – an analysis using National Health Service data. Injury. 2014;45(8):1256-1261. doi:10.1016/j.injury.2014.05.009
15) Selby R, Geerts WH, Kreder HJ, Crowther MA, Kaus L, Sealey F. Symptomatic venous thromboembolism uncommon without thromboprophylaxis after isolated lower-limb fracture: the knee-to-ankle fracture (KAF) cohort study. J Bone Joint Surg Am. 2014;96(10):e83. doi:10.2106/JBJS.M.00236
16) Bruntink MM, Groutars YME, Schipper IB, et al. Nadroparin or fondaparinux versus no thromboprophylaxis in patients immobilised in a below-knee plaster cast (PROTECT): A randomised controlled trial. Injury. 2017;48(4):936-940. doi:10.1016/j.injury.2017.02.018
17) Hickey BA, Watson U, Cleves A, et al. Does thromboprophylaxis reduce symptomatic venous thromboembolism in patients with below knee cast treatment for foot and ankle trauma? A systematic review and meta-analysis. Foot Ankle Surg. 2018;24(1):19-27. doi:10.1016/j.fas.2016.06.005
18) Samama CM, Lecoules N, Kierzek G, et al. Comparison of fondaparinux with low molecular weight heparin for venous thromboembolism prevention in patients requiring rigid or semi-rigid immobilization for isolated non-surgical below-knee injury. J Thromb Haemost. 2013;11(10):1833-1843. doi:10.1111/jth.12395
19) Testroote M, Stigter WA, Janssen L, Janzing HM. Low molecular weight heparin for prevention of venous thromboembolism in patients with lower-leg immobilization. Cochrane Database Syst Rev. 2014;(4):CD006681. Published 2014 Apr 25. doi:10.1002/14651858.CD006681.pub3
20) Zee AA, van Lieshout K, van der Heide M, Janssen L, Janzing HM. Low molecular weight heparin for prevention of venous thromboembolism in patients with lower-limb immobilization. Cochrane Database Syst Rev. 2017;8(8):CD006681. Published 2017 Aug 6. doi:10.1002/14651858.CD006681.pub4
21) Braithwaite I, Healy B, Cameron L, Weatherall M, Beasley R. Lower limb immobilisation and venous thromboembolism risk: combined case-control studies. Postgrad Med J. 2017;93(1100):354-359. doi:10.1136/postgradmedj-2016-134365
22) Engbers MJ, Blom JW, Cushman M, Rosendaal FR, van Hylckama Vlieg A. The contribution of immobility risk factors to the incidence of venous thrombosis in an older population. J Thromb Haemost. 2014;12(3):290-296. doi:10.1111/jth.12480
23) Mangwani J, Sheikh N, Cichero M, Williamson D. What is the evidence for chemical thromboprophylaxis in foot and ankle surgery? Systematic review of the English literature. Foot (Edinb). 2015;25(3):173-178. doi:10.1016/j.foot.2014.07.007
24) Nemeth B, van Adrichem R, Nelissen R, le Cessie S, Cannegieter SC. Individualized Thromboprophylaxis in Patients with Lower-Leg Cast Immobilization-A Validation and Subgroup Analysis in the POT-CAST Trial. Thromb Haemost. 2019;119(9):1508-1516. doi:10.1055/s-0039-1693410
25) Douillet D, Nemeth B, Penaloza A, et al. Venous thromboembolism risk stratification for patients with lower limb trauma and cast or brace immobilization. PLoS One. 2019;14(6):e0217748. Published 2019 Jun 20. doi:10.1371/journal.pone.0217748
26) Haque S, Davies MB. Oral thromboprophylaxis in patients with ankle fractures immobilized in a below the knee cast. Foot Ankle Surg. 2015;21(4):266-268. doi:10.1016/j.fas.2015.02.002