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

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

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

Background Incidence of DVT in patients with ankle fractures : unknown

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

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

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

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

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

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

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

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

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

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

Weight bearing status Full weight bearing:72 Partial weight bearing:9 Non weight bearing:19

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

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

DVT Age, SexPredisposing factors 67, FNone 53, MBMI=31.6, smoker 18, FBMI=28.3, smoker 69, FBMI= , MBMI=28.4, smoker

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

Discussion Annual incidence of DVT in the western population is 0.1% Silverstein et al; Archives of Internal Medicine, 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.

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

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

Discussion AuthorPatients includedIncidence of DVT Kujath et al, 1993 n=127 Lower limb injuries16.5% Kock et al, 1996 n=163 Lower limb injuries4.3% Jorgensen et al, 2002 n=106 Lower limb injuries20% Lassen et al, 2002 n=187 Lower limb injuries; included post-op as well 19%

Prophylaxis in UK Thromboprophylaxis for ankle #% of hospitals surveyed All patients8.6 (n=6) Only if pt was admitted17.2 (n=12) Only for high risk patients5.7 (n=4) No prophylaxis62.8 (n=44) Batra et al; Injury, 2006

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

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