Venous Thromboembolism in Upper Extremity Fractures

Abstract

Background: Venous thromboembolism (VTE) has been studied in lower extremity fractures but little is known of its relation with upper extremity (UE) fractures. As an often overlooked but serious complication, VTE may compromise patient outcomes. Methods: Using data on inpatients (aged ≥ 18 years) at a level-I trauma center and patients in the National Surgical Quality Improvement Program database who sustained UE fractures (clavicle, humerus, or radius/ulna) and VTE in the same hospitalization between 2007 and 2014, the authors analyzed data on demographic characteristics, fracture type, VTE location (pulmonary embolism, lower extremity, or UE), VTE onset, polytrauma, operative or nonoperative management, comorbidities, and mortality.Results: Of 1984 inpatients with UE fractures at 1 instution, 9 experienced VTE on admission, and 17 (15 received thromboprophylaxis) experienced VTE during hospitalization, for an overall VTE rate of 1.3%. VTE occurred most often in patients with fractures of the proximal humerus (3.0%) followed by the clavicle (2.0%), midshaft humerus (1.9%), distal radius/ulna (0.95%), and distal humerus/elbow (0.36%) (p = 0.0035). There were no significant trends in the incidence of PE (p = 0.33) over the study period, but there was a sharp rise since 2011. In the national database, 42 of 11570 (0.36%) patients with UE fracture had VTE, with incidence by fracture location ranging from 0.14% (radius/ulna) to 0.98% (proximal humerus) (p = 0.00001). Predictors were chronic steroid use (odds ratio [OR] = 6.22, p = .030), inpatient status (OR = 4.09, p = .002), and totally disabled functional status (OR = 3.31, p = .021). Conclusions: VTE incidence was highest following proximal humerus or clavicle fractures and are rarely associated with radius/ ulna fractures. There may have been a rise in the incidence of PE since 2007, warranting further investigation.

Deep Venous Thrombosis after Conservative Treatment of Clavicular Fracture in COVID-19 Negative Children: Two Case Reports

“…Both conservative and surgical treatment of clavicular fracture can be complicated by deep venous thrombosis (DVT). The estimated incidence of upper extremity DVT in children is 0.4 to 1 per 100,000 patients (10)(11)(12)(13)(14)(15). DVT in the upper limbs can be distinguished by 2 categories: primary and secondary (12).…”

“…Clinical examination, duplex ultrasonography of the venous system and elevation of D-dimers are used for diagnosis of upper limb deep venous thrombosis (9)(10)(11)(12)(13)(14). Up to 50% of patients can be asymptomatic.…”

Recommendations from the ICM-VTE: Shoulder & Elbow

“…Hoxie et al, reported PE rate of 5.1% (7/137) in consecutive series of 137 arthroplasty for fracture 16 . For proximal humerus ORIF, Nayar et al, in another registry study reported VTE rate of 3.0% and also reported a 0.36% VTE for fractures around distal humerus/ elbow 18 . Thus, proximal humerus fracture surgery can be considered major concerning VTE risk.…”

Considerations for Perioperative Thromboembolic Risk Mitigation in Actively and Recently COVID-19-Positive Patients Undergoing Hand Surgery

“… 11 Additionally, total joint arthroplasty literature has demonstrated a lower incidence of postoperative DVT in patients receiving total intravenous anesthesia versus general or combined spinal epidural anesthesia for total knee arthroplasty (4.48% vs 15.87 and 14.93, respectively [ P 0.05]). 30 Although a much rarer occurrence in patients with upper extremity trauma versus lower extremity trauma, the rate of VTE following upper extremity fractures ranges from 0.95% in the distal radius/ulna to 3.0% in the proximal humerus, 31 representing a clinically significant complication. In patients with a traumatic insult, undergoing potentially lengthy surgery, who are also COVID-positive, and thus, in a hypercoagulable state, the surgeon must have a low index of suspicion for thrombotic complications and consider using a method of anesthesia that mitigates this risk .…”