Fatal Pulmonary Embolism

Many of these patients have other morbidities or conditions (infection, advanced age, immobility, poor cardiac reserve, chronic venous insufficiency) that may predispose them to thrombogenesis. The physical reserves of these patients are often reduced, rendering them more vulnerable to succumb to an embolism that would not necessarily be fatal in fitter patients. Autopsy studies suggest that fatal pulmonary embolism (PE) is a common cause of death in this group of patients.¹ However, this group is also vulnerable to death from many other causes such as pneumonia, myocardial infarction, bed sores, and infection. PE may be only a contributing factor in their demise. It is therefore difficult to determine reliably the fatal PE rate after hip fracture without prophylaxis; perhaps it is approximately 1%.

Symptomatic Venous Thromboembolism

The frequency of venographic deep vein thrombosis (DVT) after hip fracture without prophylaxis is unclear because so few studies have been conducted; a rate of approximately 50% is likely. The rates of symptomatic DVT and PE are similarly difficult to adduce because there are no unconfounded epidemiologic studies or clear data from the placebo arm of randomized controlled trials. A figure of approximately 5% is reasonable. The longer-term risk of chronic venous insufficiency is also unknown. Many patients with hip fracture are predisposed to this problem regardless of their fracture; many are in an age group who will not live long enough to develop this longer-term complication.

Hypercoagulability

The fractured bone releases thromboplastins into the circulation. This process induces hypercoagulability, which is compounded by the subsequent surgical procedure. The hypercoagulability may last for several weeks.²

Venous Stasis

Venous stasis occurs as soon as the patient falls and is unable to bear weight. There is often a substantial delay before the patient is found and is taken to a medical facility. The maneuvers required to reduce the hip fracture cause further venous stasis.³

Endothelial Damage

The maneuvers required to expose and reduce a hemiarthroplasty or a displaced pertrochanteric fracture may also damage the venous endothelium.⁴

General Measures

Mechanical Methods

Orthopaedic surgeons have to balance risk and benefit in the perioperative period. Therefore, they intuitively find mechanical methods appealing because these methods carry no bleeding risk. All mechanical methods have the disadvantages of expense and noncompliance. Furthermore, these methods are not practical for, nor is there evidence for, extended prophylaxis. Very few data are derived from hip fracture patients. However, one can reasonably extrapolate from other surgical studies.

Chemical Methods

Chemical methods are generally easy to administer (tablet or injection) and can be used for an extended duration. They are fairly inexpensive relative to the overall cost of surgery. However, orthopaedic surgeons are properly concerned about the risk of bleeding inherent in the use of these agents.

Related posts:

Rehabilitation: Improving Outcomes for Patients Following Fractures of the Proximal Femur Epidemiology/Population Studies: Scope of the Problem Femoral Neck Fractures: Treatment of Nonunion Femoral Neck Fractures: Reduction and Fixation Subtrochanteric Fractures: Intramedullary Fixation Complications of Trochanteric Fractures

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