DVT with ankle fractures: Is thromboprophylaxis warranted?

1. DVT with ankle fractures: Is thromboprophylaxis warranted? Sunit Patil Jamshid Gandhi Ian Curzon Anthony Hui James Cook University Hospital, Middlesbrough

2. Background • Thromboprophylaxis for patients in a plaster cast is a standard of care in many European countries Chest (2004), 126:338-400 • Incidence of DVT in patients in a plaster - about 20%

3. Background • Most studies so far have clubbed together patients with soft tissue injuries and fractures • Incidence of DVT is higher in patients with a fracture as opposed to soft tissue injury Archives of Internal Medicine, 2002

4. Background • Incidence of DVT in patients with ankle fractures : unknown

5. Research Question • What is the incidence of DVT in patients with ankle fractures treated in a below knee plaster cast?

6. Methods • Prospective study • R&D and Ethical committee approval • Consecutive patients with ankle fractures treated at JCUH

7. Methods • Patients were identified from fracture clinic • Exclusion criteria: • Previous DVT • Patients already on thromboprophylaxis • Patients treated with methods other than plaster • Patients requiring surgery

8. Methods • At 6/52: • Cast removal • Clinical assessment • Colour duplex ultrasound scan

9. Ultrasound • Colour duplex ultrasound has a sensitivity of 96% and negative predictive value of 99% Journal of thrombosis and haemostasis, 2006 • Doppler ultrasound is the most universally accepted diagnostic test for lower extremity DVT ACCP guidelines, 2004

10. Ultrasound • Scans were performed by one of the two experienced musculoskeletal ultrasound technicians • Philips IU22 duplex colour doppler ultrasound

11. Protocol for patients with DVT • Above knee DVT • Below knee DVT • Repeat scan at 1/52 Anti-coagulate Treated as per consultant

12. Results 112 patients 8 declined to participate 3 required ORIF 1 was started on prophylactic LMWH by geriatrician 100 patients

13. Results • Males: 51 Females: 49 • Mean age: 43 years (16-79) • Mean BMI: 28 (18-51) • Smokers: 29 • Mean duration of plaster cast: 6/52 (3-7)

14. Types of fractures • Weber A: 19 • Weber B: 69 • Weber C: 1 • Medial malleolus: 9 • Tillaux fracture: 2

15. Weight bearing status • Full weight bearing: 72 • Partial weight bearing: 9 • Non weight bearing: 19

16. DVT • Superficial femoral vein: 1 • Popliteal vein: 1 • Posterior tibial vein + peroneal vein: 1 • Peroneal vein: 2

17. DVT • All 5 were asymptomatic and had no clinical signs of DVT • All 5 were FWB during the period of immobilisation

18. DVT

19. Results • None of the DVTs propagated on a scan done a week later • None developed symptoms or signs of PE

20. Discussion • Annual incidence of DVT in the western population is 0.1% Silverstein et al; Archives of Internal Medicine, 1998. • Cumulative probability of venous thromboembolism by the age of 50 is 0.5% and by 80 is 3.8%. Hansson et al; Archives of Internal Medicine, 1997.

21. Discussion • DVT following THR/TKR: 40-80% • Clinical PE: 4-10% • Fatal PE: 0.5-2% Source: Geerts et al, Chest 2004

22. Discussion • Our findings suggest a 5% incidence of DVT • 95% confident • Overall incidence of DVT is <9% • Incidence of above knee DVT is <5%

23. Discussion

24. Prophylaxis in UK Batra et al; Injury, 2006

25. Conclusion • Incidence of DVT following ankle fractures is 5% • Routine thromboprophylaxis is not justified If it ain’t broke, don’t fix it!

26. Acknowledgment • We would like to thank the entire staff of the Orthopaedic Department, JCUH, for their support • Special thanks to Alison Gamble, Chris Cummins (ultrasound technicians) and Dr. R Bellamy • This project was funded by the Orthopaedic Department, James Cook University Hospital, Middlesbrough