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DVT & PE arising from Trauma, Pelvic Fractures, and Extremity Fractures

- See: DVT Discussion:

- Discussion:
    - 30-50 % occurance of DVT in trauma pts w/ lower extremity fractures;
    - preexisting conditions such as heart disease, obesity, carcinoma, diabetes, and hypertension could theoretically push the numbers even 
    - mortality for pulmonary embolism may approach 10%;
    - ref: Use of the Low-Molecular-Weight Heparin Reviparin to Prevent Deep-Vein Thrombosis after Leg Injury Requiring Immobilization
    - DVT in acetabular frx:
           - DVT occurs in about 1/3 of patients;
                 - occurs in 1/5 patients less than 40;
                 - occurs in 1/2 of patients over 40;
           - risk of pulmonary embolism is about 4-7%;
           - in the study by JP Stannard et al, DVT developed in betwee 13% to 19% depending on the form of DVT prophylaxis;
           - increased patient age and the time elapsed from the injury to the surgery were found to be associated with higher rates of thrombosis;
           - ref: Mechanical Prophylaxis Against Deep-Vein Thrombosis After Pelvic and Acetabular Fractures 

- Clinical Signs:
    - clinical signs are unreliable but should not be ignored;
    - calf tenderness, swelling, fever, & increased pulse rate may be present.

- Diagnosis by MRI:
    - may emerge as the new gold standard for diagnosis of DVT, esp in trauma patients;
    - can diagnosis pelvic DVT, and can be used to diagnose DVT in patients who have femoral or tibial frx;

- Prevention:
    - coumadin, low molecular wt dextran, adjusted dose heparin, or low molecular wt heparin are proven effective for
           pts undergoing elective surgery;
    - vena cava filter:
           - in multi-trauma patients consider prophylactic placement of a vena cava filter;
           - decrease in incidence of pulmonary embolism can be expected;
           - filters should remove 98% of emboli;
           - filters can be expected to prevent fatal emboli in about 2-4% of patients undergoing major acetabular fixation (as compared to
                   patients who receive other forms of DVT prophylaxis);
           - long term patency rate of IVC is about 94% at 1-2 years;
           - sudden severe leg edema following filter insertion may indicate the occurance of a large embolus;
           - criteria for filter placement (2/5 criteria must be met);
                  - age greater than 55 yrs;
                  - ISS greater than 16;
                  - complex pelvic fracture;
                  - long bone and pelvic fracture;
                  - fracture (pelvic / lower extremity) requiring prolonged bed rest;
           - in the study by Wojcik et al (2000), the authors sought to determine the long-term complications of VCF placement;
                  - there were 191 VCFs inserted in our trauma population from 1993 to 1997;
                  - there were 105 patients (75 male and 30 female) available for evaluation, with a mean follow-up of 28.9 months;
                  - 41 VCFs were placed in patients with DVT or pulmonary embolism, and 64 were placed in patients for prophylactic indications;
                  - there were no clinically identifiable complications related to insertion of the VCF;
                  - there were no pulmonary embolisms detected after VCF insertion;
                  - only one filter (0.95%) migrated, and this was minimal (1 cm cephalad);
                  - 1 (0.95%) vena cava was occluded, based on duplex ultrasonography, and 11 patients (10.4%) had signs or symptoms of leg 
                         swelling after hospital discharge;
                  - 28 (44%) of the 64 patients with prophylactic VCFs developed a DVT after filter placement;
                  - VCFs placed in trauma patients have acceptable short- and long-term complication rates;
                  - consideration should be given to prophylactic VCF placement in patients at high risk for VTE;
                  - randomized controlled trials are needed to evaluate whether VCF insertion increases the risk for subsequent DVT 
                  - ref: Long-Term Follow-Up of Trauma Patients with a Vena Caval Filter

Prophylactic Vena Cava Filter Insertion in Severely Injured Trauma Patients: Indications and Preliminary Results.

Magnetic resonance venography to evaluate the deep venous system of the pelvis in patients who have an acetabular fracture.

Prevention of deep vein thrombosis and pulmonary embolism in acetabular and pelvic fracture surgery.

Prophylactic Vena Cava Filter Insertion in Selected High Risk Orthopaedic Trauma Patients

Greenfield filter prophylaxis of pulmonary embolism in patients undergoing surgery for acetabular fracture

Thromboembolism following multiple trauma.

Risk of pulmonary emboli in patients with pelvic fractures.

Prophylaxis Against Deep-Vein Thrombosis Following Trauma: A Prospective, Randomized Comparison of Mechanical and Pharmacologic Prophylaxis.

Long-Term Consequences of Pelvic Trauma Patients With Thromboembolic Disease Treated With Inferior Vena Caval Filters.

Prophylaxis of deep-vein thrombosis in fractures below the knee