Pulmonary embolism following fixation in a

lower extremity fracture: a clinical

presentation By: AJ Cushman

PurposeDiscuss potential impact of a pulmonary embolism

(PE)/deep vein thrombosis (DVT) on recovery from a traumatic injury.

My Patient-Mr. Salesman27 y/o African-American maleCar salesmanRuns 3 miles dailyNo family hx, prior sx, comorbiditiesLives with fatherAdmitted May 26, 2014 for gun shot wound (GSW)

History of present illnessORIF of L distal femur fx s/p GSW

TTWB LLEHgb dropped: 125.0 mmHgTachycardic/orthostatic: 130180bpm on standing

Transferred to STICUC/o pain RLE

Possible DVT/PE Chest CT found small/moderate PE L lower lobe.

Heparin bolus

PT EvaluationSubjective

8/10 pain R (uninjured) > L at

beginning of session L > R at end

Odd sensations in L foot Activity Level Living Situation/equipment

With father, stairs, crutches

Goals

Objective Observe: lethargic Vitals: Tachycardic throughout Integument: clammy,

temperature R>L, Swelling L>R

Sensation: L=paresthesias, R=pain

ROM: R-WFLs, L-0-35˚ knee flexion

Mobility: supineEOB, sitstand, ambulation

Relevant FindingsPain (BLE) Decreased strength Decreased ROM (L knee flexion) Ability to maintain WB statusActivity tolerance/enduranceIndependence with ambulation and ADLs…

Prognosis and GOALSPt is good candidate for PTLikely return to previous level of function and d/c

home (+)- age, prior activity level, no comorbidities, pt

motivation, cognition, family assistance at home (-)- severity of pain and injuries, level of dysfunction,

and…complications aka DVT/PE???

Goals and PlanAt time of discharge (1 week), patient will be able

to:1) Actively achieve 90 degrees of knee flexion2) Ambulate 150 feet independently using LRAD3) Up/down one flight of stairs using LRAD

Plan: 5x/wk. Expected d/c = home

InterventionsFunctional mobility(Gait training)Therapeutic exerciseActivity Tolerance

Increase endurance

Patient education WB status DVT/PE

Outcomes/Re-eval Assessment of re-eval…Goals Met (1/3): Pt able to achieve 90˚ L knee

flexionRationale for other goals NOT met:

Delays in PT visitsUnable to ambulate/maintain WB status

Information I am missing…

Does the incidence of a pulmonary embolism negatively impact the prognosis in a healthy, young adult recovering from a lower extremity fracture?

A meta-analysis of best rest versus early ambulation in the

management of pulmonary embolism, deep vein thombosis, or both.

International Journal of Cardiology; Volume 137, Issue 1, Pages 37-41

Nadia Aissaoui, Edith Martins, Stéphane Mouly, Simon Weber and Christophe Meune

Copyright 2008 Elsevier Ireland Ltd

PurposeDetermine the best recommendation for PE/DVT

managementAmbulation versus bed restAlong with anticoagulants

Previous arguments in literature versus recent articlesEnd to confusion?

Method5 studies selected (out of original 363 found)

comprising a total of 3048 patientsInclusion criteria:Relative risk (RR), 95% confidence intervals (CI)

ResultsEarly ambulation:

1. Not associated with higher risk of new PE

(RR 1.03, 95% CI 0.65-1.63)

2. Associated with a lower trend of new/progression of DVT

(RR 0.79; 95% CI 0.55–1.14)

3. Not associated with higher rate of mortality

(RR 0.79, 95% CI 0.40-1.56)

Discussion and ConclusionMust achieve effective level of anticoagulation

first!Confirmed efficacy as first line

EARLY AMBULATION DOES NOT INCREASE RISK OF ADVERSE OUTCOMES Trend toward lower risk in previously stated areas

Other positive benefits…

Study LimitationsTiming of early ambulation range = 0-2 daysAddition of compression devices not assessedMassive PE excludedNo distinction between:

PE and DVT symptomatic and asymptomatic PE

The effect of anticoagulant

pharmacotherapy on fracture healing

Tobias Lindner, Andrew J Cockbain, Mohamed A El Masry, Paul Katonis, Evgenios Tsiridis, Constantin Schizas &

Eleftherios Tsiridis

Expert Opin. Pharmacother. (2008) 9(7):1169-1187

PurposeConsider potential recommendations between

specific agents and dosage in trauma patients (ie fracture)Current guidelines distinguish between low versus

high risk (provoked and idiopathic)

Presents evidence concerning the effect of common anticoagulants on:1) Fracture healing (in vivo) - 7 studies2) Bone metabolism (in vivo) – 6 studies3) Bone cells (in vitro) – 8 studies

Anticoagulants in clinical use

HeparinLow molecular weight heparins (LMWHs) (Enoxaparin)Synthetic pentasaccharides (Fondaparinux)Vitamin K antagonists (Warfarin/coumarins)Acetylsalicylic acid (aspirin, Bayer Leverkusen)Direct thrombin inhibitors (DTIs) (argatroban,

lepirudin and hirudin)HIT alternative

Biology of fracture healing

Anticoagulants on fracture healing (in vivo)

Warfarin Heparin LMWH AspirinStudy #1 *Worst

union delay with earlier Rx

*Worst union delay with earlier Rx

Study #2 NO LONGER CLINICAL

Study #3 Hard callus formation (>soft)

Study #4 Bone formation & strength

Study #5 Bone formation

No impair

Study #6 No impair No impairStudy #7 No impair

Anticoagulants on bone biology (in vivo)

Warfarin Heparin LMWHStudy #1 Bone

form/resorb (osteocalcin)

Study #2 Cancellous bone (inc resorb, dec form)

Cancellous bone (dec form only)

Study #3 Same as #3 Same as #3Study #4 *Prolonged

effects ≥56days

Study #5 Bone volume and strength (both ends)

Study #6 Bone mineral content

Not significant

Anticoagulants on bone cells (in vitro)

Heparin LMWH FondaparinuxStudy #1

Bone nodule formation (greater osteoporosis risk than LMWH)

Bone nodule formation

Study #2

Cell concentration (osteoblast growth)

Cell concentration (osteoblast growth)

Study #3

Gene expression Gene expression *Inc matrix calcium/type 1 collagen)

Study #4

*Biphasic effect (low vs high dose)

Study #5

Osteoblast/gene expression (4x)

Osteoblast/gene expression

Study #6

Blast prolif, protein synthesis, osteocalcin

No inhib

Study #7

Osteoblast/osteocalcin

Study #8

Osteoclast formation

Discussion

Anticoagulants impair fracture healing and bone health

All different stages in healing

Considerations Type

Heparin, Warfarin, and aspirin are worst

LMWHs are better Fondaparinux is best per this review

(further study required)

Dosage Less is more

Onset Immediate = worst Early mechanical thromboprophylaxis

Duration Early termination in patients with

provoked PE

Study LimitationsLack of clinical studies

Must assume adequate comparison between animal and human

Unknown degree/significance of effectsVariable mechanisms expressed

Method for study selectionNot systematic

According to the research…

DOES MR. SALESMAN’S PE NEGATIVELY AFFECT HIS

PROGNOSIS?

Short termNOAmbulation recommended. Begin addressing his

problem list without restriction (once properly anticoagulated) Length of stay not increased

Patient will have altered WB status with or without anticoagulants

Long Term(+) Provoked = lower risk of reoccurrence

No issue resuming independence with work and ADLs (-) Provoked = prescribed anticoagulants for 3-6

months…Delay fx healing delay normal WB progression?Residual effects?

NO CONCLUSION on severity and duration of Heparin effectsPatient education of potential riskSlower progression of WB and return to running Imaging?

Heparin LMWH Warfarin Aspirin Fondaparinux

Union delaysBone strengthOsteoblastOsteoclast

Heparin LMWH Warfarin Fondaparinux

-Delayed unions-Bone formation

-Delayed unions-Soft callus > hard callus