American Association for Hand Surgery
Theme: Beyond Innovation

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Which Patients with Upper Extremity Trauma Need Deep Vein Thrombosis or Pulmonary Embolism Prophylaxis?
Joseph Galloway, MD; Joseph A Ippolito, MD; Brianna Siracuse, B.S.; Irfan Ahmed, MD; Michael Vosbikian, M.D
Rutgers New Jersey Medical School, Newark, NJ

INTRODUCTION: Despite previous studies which have defined the risk of deep vein thrombosis (DVT) and pulmonary embolism (PE) in patients with orthopedic trauma to the lower extremities, limited data exists regarding prediction of risk of DVT and PE following orthopedic trauma to the upper extremities. The objective of this study was to develop a predictive scale to identify patients at increased risk for DVT or PE following isolated upper extremity orthopedic trauma.
METHODS: There were 157,723 recorded patients with isolated traumatic upper extremity injuries (fractures of the clavicle, humerus, or lower arm) who did not receive DVT prophylaxis recorded in the State Inpatient Database (SID) of NY and CA between 2006 and 2014, making up the derivation cohort. There were 120,887 similar incidents making up the validation cohort from FL and WA over the same time period. After identification of risk factors with univariate and multivariate analysis in the derivation cohort, a predictive scale was generated and tested utilizing the validation cohort.
RESULTS: Overall, 1.54% of patients without DVT prophylaxis developed a DVT/PE during or shortly after being hospitalized for isolated upper extremity trauma. On multivariate analysis of the derivation cohort, advanced age, nonwhite race, Medicaid or Medicare insurance status, proximal fracture location, as well as comorbidities including anemia, lung disease, heart failure, coagulopathy, obesity, and renal failure were found to be significant predictors of DVT (Table 1), and used to create a scale that could be used preemptively to predict patients most at risk for DVT/PE (Figure 1). This scale was applied to both the derivation and validation cohorts and had R^2 values of 89.9% and 93.6%, respectively. Patients with a score less than 21 were determined to be low risk have a 0.93% risk for DVT/PE, while patients with moderate risk (score 21-30) and those at high risk (score > 30) had a DVT/PE risk of 2.10% and 3.69%, respectively in the validation cohort (p<0.0001) (Figure 2).
CONCLUSION: Approximately 1.5 percent of patients with isolated upper extremity orthopedic trauma who did not receive prophylaxis developed a DVT or PE shortly after hospitalization. With the development of this risk stratification scale clinicians are able to detect patients at increased risk for DVT/PE. Although not analyzed in this study, future works investigating the development of standardized institutional protocols to reduce DVT and PE following isolated upper extremity orthopedic trauma utilizing information within this predictive scale may be worthwhile.


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