The Journal of Bone & Joint Surgery

The Journal of Bone & Joint Surgery, Volume 78, Issue 4

Articles | April 01, 1996

Effect of Delayed Admission to the Hospital on the Preoperative Prevalence of Deep-Vein Thrombosis Associated with Fractures about the Hip*

WILLIAM F. HEFLEY, JR., M.D.†; CARL L. NELSON, M.D.‡; CHERYL L. PUSKARICH-MAY, PH.D.‡, LITTLE ROCK, ARKANSAS

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Investigation performed at the University Hospital of Arkansas and the John L. McClellan Veterans Administration Hospital, Little Rock

J Bone Joint Surg Am, 1996 Apr 01;78(4):581-3

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Abstract

Thirteen (10 per cent) of 133 patients who had venography on admission to the hospital for a fracture about the hip had radiographic evidence of deep-vein thrombosis. Only seven (6 per cent) of the 122 patients who were seen at the hospital within two days after the fracture had evidence of thrombosis. However, six of the eleven patients who had a delay of more than two days between the fracture and admission to the hospital had evidence of thrombosis. Although there was no significant difference between these two groups with respect to the mean age, sex distribution, frequency of fracture type, or history of deep-vein thrombosis, there was a significant difference in the prevalence of thrombosis in the patients who had a delay before admission to the hospital compared with those who did not (p < 0.001). These results suggest that there is a substantial risk of venous thromboembolic disease in patients who have a fracture about the hip, regardless of whether or not they have had an operation, and that this risk increases if the time to presentation is delayed. Consequently, patients for whom there was a delay between a fracture about the hip and admission to the hospital should be considered to be at high risk for, and should be evaluated for, deep-vein thrombosis preoperatively.

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Introduction

Introduction | Materials and Methods | Results | Discussion | References

Venous thromboembolic disease occurs frequently in patients who have a fracture about the hip. The prevalence of deep-vein thrombosis in the lower extremities of patients with such a fracture who did not receive protective anticoagulation has been reported to be between 40 per cent (of 100 patients) and 83 per cent (of thirty-five patients)^3,8,14-16, and the rate of fatal pulmonary embolism has ranged from 4 per cent (of forty-five patients) to 38 per cent (of 247 patients)^1,3,6,14.

Patients who have a fracture about the hip are considered to be at increased risk for venous thromboembolic disease even before operative treatment because of trauma to and immobilization of the extremity as well as other factors that are commonly present, such as advanced age, obesity, and associated medical problems⁷. However, only a few investigators have attempted to document the prevalence of thromboembolic disease that may already be present in these high-risk patients at the time of admission to the hospital. In two reported series of patients examined venographically before an operation, the preoperative prevalence of deep-vein thrombosis ranged from 9 per cent (of 176 patients)¹² to 13 per cent (of seventy-one patients)¹⁵. The issue of potential risk factors that might influence these values has not been adequately addressed.

The purpose of the present study was to establish the prevalence, on admission to the hospital, of venous thromboembolic disease in patients who had a fracture about the hip and to determine what factors might have influenced this prevalence. Specifically, we examined the effect of the time from the fracture to presentation on the risk of preoperative deep-vein thrombosis.

*No benefits in any form have been received or will be received from a commercial party related directly or indirectly to the subject of this article. No funds were received in support of this study.

†Arkansas Orthopaedic Associates, 1 St. Vincent Circle, Suite 210, Little Rock, Arkansas 72205.

‡Department of Orthopaedic Surgery, University of Arkansas for Medical Sciences, 4301 West Markham, Slot 531, Little Rock, Arkansas 72205-7199.

*No benefits in any form have been received or will be received from a commercial party related directly or indirectly to the subject of this article. No funds were received in support of this study.

†Arkansas Orthopaedic Associates, 1 St. Vincent Circle, Suite 210, Little Rock, Arkansas 72205.

‡Department of Orthopaedic Surgery, University of Arkansas for Medical Sciences, 4301 West Markham, Slot 531, Little Rock, Arkansas 72205-7199.

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TABLE I COMPARISON OF THE PATIENTS WHO HAD DEEP-VEIN THROMBOSIS WITH THOSE WHO DID NOT

* The values are given as the mean and the standard deviation.†The values are given as the numbers of patients.

	Patients Who Had Deep-Vein Thrombosis	Patients Who Did Not Have Deep-Vein Thrombosis
No. of patients	13	120
Age* (yrs.)	71 ± 9	70 ± 13
Sex (M/F)†	9/4	88/32 (73%/27%)
History of Thrombo-
embolic disease†
Yes	0	5 (4%)
No	13	115 (96%)
Type of fracture†
Femoral neck	8	70 (58%)
Intertrochanteric	5	50 (42%)

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TABLE I COMPARISON OF THE PATIENTS WHO HAD DEEP-VEIN THROMBOSIS WITH THOSE WHO DID NOT

* The values are given as the mean and the standard deviation.†The values are given as the numbers of patients.

	Patients Who Had Deep-Vein Thrombosis	Patients Who Did Not Have Deep-Vein Thrombosis
No. of patients	13	120
Age* (yrs.)	71 ± 9	70 ± 13
Sex (M/F)†	9/4	88/32 (73%/27%)
History of Thrombo-
embolic disease†
Yes	0	5 (4%)
No	13	115 (96%)
Type of fracture†
Femoral neck	8	70 (58%)
Intertrochanteric	5	50 (42%)

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TABLE II PREVALENCE OF PREOPERATIVE DEEP-VEIN THROMBOSIS ACCORDING TO TIME OF ADMISSION TO THE HOSPITAL*

*The values are given as the numbers of patients.

	Admission
	=2 Days after Fracture	>2 Days after Fracture
Total no. of patients	122	11
Distal deep-vein thrombosis	4 (3%)	4
Proximal deep-vein thrombosis	3 (2%)	2
Total no. of patients	7 (6%)	6
with deep-vein thrombosis

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TABLE II PREVALENCE OF PREOPERATIVE DEEP-VEIN THROMBOSIS ACCORDING TO TIME OF ADMISSION TO THE HOSPITAL*

*The values are given as the numbers of patients.

	Admission
	=2 Days after Fracture	>2 Days after Fracture
Total no. of patients	122	11
Distal deep-vein thrombosis	4 (3%)	4
Proximal deep-vein thrombosis	3 (2%)	2
Total no. of patients	7 (6%)	6
with deep-vein thrombosis

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TABLE III COMPARISON OF PATIENTS ADMITTED WITHIN TWO DAYS AFTER FRACTURE WITH THOSE ADMITTED MORE THAN TWO DAYS AFTER FRACTURE

*The values are given as the mean and the standard deviation.†The values are given as the numbers of patients.

	Patients Admitted =2 after Fracture	Patients Admitted >2 after Fracture
No. of patients	122	11
Age* (yrs.)	70 ± 14	72 ± 9
Sex (M/F)†	79/43 (65%/35%)	6/5
History of thrombo- embolic disease† Yes No	5 (4%) 117 (96%)	0 11
Type of fracture† Femoral neck Intertrochanteric	63 (52%) 59 (48%)	5 6

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TABLE III COMPARISON OF PATIENTS ADMITTED WITHIN TWO DAYS AFTER FRACTURE WITH THOSE ADMITTED MORE THAN TWO DAYS AFTER FRACTURE

*The values are given as the mean and the standard deviation.†The values are given as the numbers of patients.

	Patients Admitted =2 after Fracture	Patients Admitted >2 after Fracture
No. of patients	122	11
Age* (yrs.)	70 ± 14	72 ± 9
Sex (M/F)†	79/43 (65%/35%)	6/5
History of thrombo- embolic disease† Yes No	5 (4%) 117 (96%)	0 11
Type of fracture† Femoral neck Intertrochanteric	63 (52%) 59 (48%)	5 6

Materials and Methods

Introduction | Materials and Methods | Results | Discussion | References

One hundred and thirty-three patients who were admitted to the University Hospital of Arkansas or the John L. McClellan Veterans Administration Hospital between April 1987 and October 1989 with a diagnosis of a fracture of the femoral neck or an intertrochanteric fracture of the femur had bilateral venography of the lower extremity performed immediately after admission. Seventy (53 per cent) of the 133 patients also had a ventilation-perfusion lung scan on admission. The time from the fracture to presentation as well as the results of the venography and the ventilation-perfusion lung scan, if performed, were recorded for each patient. The age and sex of the patient, the type of fracture, any history of thromboembolic disease, and any comorbidities were also recorded.

All of the venograms were made with diatrizoate meglumine (Hypaque Meglumine, 60 per cent) with the technique of Rabinov and Paulin. The venograms were interpreted by radiologists on the staff of the two participating hospitals. The criteria for a positive venogram were a persistent intraluminal filling defect on two radiographs, abrupt termination of a vein, or non-opacification of the deep system. Thrombi were classified as distal or proximal on the basis of their relationship to the venous trifurcation.

The prevalences of venographically documented preoperative deep-vein thrombosis in the patients who were admitted to the hospital more than two days after the fracture and in those who were admitted within two days after the fracture were compared statistically with use of the chi-square test. Comparisons between these two groups with respect to the mean age, sex distribution, frequency of fracture type, and history of venous thromboembolic disease were conducted with a Student t test or chi-square test for continuous and proportional data, respectively. A p value of 0.05 or less was considered significant for all comparisons.

Results

Introduction | Materials and Methods | Results | Discussion | References

Thirteen (10 per cent) of the 133 patients who had venography on admission had evidence of deep-vein thrombosis. Eight had distal thrombi and five had proximal thrombi. The deep-vein thrombosis was in the ipsilateral limb in six patients, in the contralateral limb in three, and bilateral in four.

The mean age (and standard deviation) of the thirteen patients who had venographic evidence of preoperative deep-vein thrombosis was 71 ± 9 years, compared with 70 ± 13 years for the 120 patients who did not have evidence of thrombosis. Eight of the thirteen patients had a fracture of the femoral neck, which was impacted in two, and five had an intertrochanteric fracture (Table I). None of these patients had a history of deep-vein thrombosis (Table I), although one patient had had a previous operation on a lower extremity. With the numbers available, we could detect no significant difference (p > 0.05) in the mean age, sex distribution, frequency of fracture type, or history of thromboembolic disease between the patients who had documented deep-vein thromboses on admission and those who did not (Table I).

Five patients had a known malignant tumor on admission. One of these patients had bilateral deep-vein thrombosis, which was distal on the ipsilateral side and proximal on the contralateral side. None of the five patients who were admitted with congestive heart failure had positive findings on the venograms.

The frequency of deep-vein thrombosis was calculated according to the time between the fracture and admission to the hospital (Table II). One hundred and twenty-two (92 per cent) of the 133 patients were seen at the hospital within two days after the fracture about the hip. Seven (6 per cent) of these patients had venographically documented deep-vein thrombosis, which was distal in four patients (3 per cent) and proximal in three (2 per cent).

Eleven (8 per cent) of the 133 patients had a delay of more than two days from the fracture to presentation at the hospital. The mean delay for the eleven patients was 8 ± 5 days (range, three to twenty days). Six of the eleven patients had venographically documented deep-vein thrombosis on admission, which was distal in four and proximal in two (Table II). Five patients had a fracture of the femoral neck, which was not impacted (Table III). With the numbers available, we could detect no significant difference (p > 0.05) in the mean age, sex distribution, frequency of fracture type, or history of previous thromboembolic disease between the patients who were seen within two days after the fracture and those who were seen more than two days after it (Table III). However, the difference in the prevalence of deep-vein thrombosis between these groups was significant (p < 0.001).

A ventilation-perfusion lung scan was made for seventy of the 133 patients on admission. Two (3 per cent) of these patients had a high probability for pulmonary embolism but were asymptomatic and did not have deep-vein thrombosis. No patient had a fatal pulmonary embolus preoperatively.

Discussion

Introduction | Materials and Methods | Results | Discussion | References

Thirteen (10 per cent) of 133 patients who had a fracture about the hip had deep-vein thrombosis on admission to the hospital. The patients for whom admission was delayed more than two days had a higher prevalence of deep-vein thrombosis (six of eleven) than those who were seen within two days after the fracture (seven of 122;6 per cent). These data support the findings of Stevens et al., who reported a 13 per cent prevalence of deep-vein thrombosis in seventy-one patients before operative treatment of a fracture of the femoral neck and suggested that the frequency of the complication increased as the time from the fracture to venography increased. Fenech et al., using nuclear medicine scans with radiolabeled platelets, found preoperative venous disease in four of eleven patients. In a previous study from our institution¹², sixteen (9 per cent) of 176 patients who had a fracture about the hip had preoperative deep-vein thrombosis. However, no effort was made to determine the effect of a delay in presentation on the prevalence of deep-vein thrombosis.

The results of the present study suggest that there is a high risk of deep-vein thrombosis in patients who have a fracture about the hip and that this risk is unrelated to the treatment that the patient ultimately receives. It is interesting to note that the prevalence of deep-vein thrombosis in this small series of patients is similar to that reported in patients with a fracture of the hip who were studied venographically several days after the fracture but who, in the interim, had been managed operatively^4,9,10,13. This information should be a consideration in the operative or non-operative management of a patient who has a fracture about the hip.

Patients who are first seen at the hospital more than two days after sustaining a fracture about the hip should be considered to be at high risk for deep-vein thrombosis. Our current practice is to perform venous duplex scans on admission for patients who are seen more than two days after a fracture about the hip. Patients who are found to have deep-vein thrombosis preoperatively are counseled regarding the risk of an intraoperative pulmonary embolus, and consideration is given to the placement of a filter in the inferior vena cava before the operation².

NOTE: The authors thank Missy Raley, Michelle Graves, Tracye Byler, and Kathy Thessing, R.N., for assistance in the preparation and editing of this manuscript.

References

Introduction | Materials and Methods | Results | Discussion | References

Ahlberg, A.; Nylander, G.; Robertson, B.; Cronberg, S.; and |and |Nilsson, I. M.: Dextran in prophylaxis of thrombosis in fractures of the hip.. Acta Chir. Scandinavica,Supplementum 387: 83-85, 1968.Supplementum 38783 1968

Collins, D. N.; Barnes, C. L.; McCowan, T. C.; Nelson, C. L.; Carver, D. K.; McAndrew, M. P.; and |and |Ferris, E. J.: Vena caval filter use in orthopaedic trauma patients with recognized preoperative venous thromboembolic disease. J. Orthop. Trauma,6: 135-138, 1992.6135 1992 [PubMed][CrossRef]

Culver, D.; Crawford, J. S.; Gardiner, J. H.; and |and |Wiley, A. M.: Venous thrombosis after fractures of the upper end of the femur. A study of incidence and site. J. Bone and Joint Surg,52-B(1): 61-69, 1970.52-B(1)61 1970

Evarts, C. M., and |and |Feil, E. J.: Prevention of thromboembolic disease after elective surgery of the hip. J. Bone and Joint Surg,53-A: 1271-1280, Oct. 1971.53-A1271 1971

Fenech, A.; Winter, J. H.; Bennett, B.; Smith, F. W.; and |and |Douglas, A. S.: Preoperative frequency of deep venous thrombosis in patients with fractured neck of femur [letter]. Lancet,1: 1212, 1981.11212 1981 [CrossRef]

Fitts, W. T. Jr.; Lehr, H. B.; Bitner, R. L.; and |and |Spelman, J. W.: An analysis of 950 fatal injuries.. Surgery,56: 663-668, 1964.56663 1964 [PubMed]

Hirsh, J.; Genton, E.; and Hull, R.: Risk factors in thrombosis. In Venous Thromboembolism, pp. 19-39. New York, Grune and Stratton, 1981.

Kakkar, V.: The diagnosis of deep vein thrombosis using the ¹²⁵I fibrinogen test. Arch. Surg,104: 152-159, 1972.104152 1972 [PubMed]

Montrey, J. S.; Kistner, R. L.; Kong, A. Y.; Lindberg, R. F; Mayfield, G. W.; Jones, D. A.; and |and |Mitsunaga, M. M.: Thromboembolism following hip fracture. J. Trauma,25: 534-537, 1985.25534 1985 [PubMed][CrossRef]

Paiement, G. D.; Wessinger, S. J.; and |and |Harris, W. H.: Survey of prophylaxis against venous thromboembolism in adults undergoing hip surgery.. Clin. Orthop,223: 188-193, 1987.223188 1987 [PubMed]

Rabinov, K., and |and |Paulin, S.: Roentgen diagnosis of venous thrombosis in the leg. Arch. Surg,104: 134-144, 1972.104134 1972 [PubMed]

Roberts, T. S.; Nelson, C. L.; Barnes, C. L.; Ferris, E. J.; Holder, J. C.; and |and |Boone, D. W: The preoperative prevalence and postoperative incidence of thromboembolism in patients with hip fractures treated with dextran prophylaxis. Clin. Orthop,255: 198-203, 1990.255198 1990 [PubMed]

Salzman, E. W, and |and |Harris, W. H: Prevention of venous thromboembolism in orthopaedic patients. J. Bone and Joint Surg,58-A: 903-913, Oct. 1976.58-A903 1976

Sevitt, S., and |and |Gallagher, N. G.: Prevention of venous thrombosis and pulmonary embolism in injured patients. A trial of anticoagulant prophylaxis with phenindione in middle-aged and elderly patients with fractured necks of femur. Lancet,2: 981-989, 1959.2981 1959 [PubMed][CrossRef]

Stevens, J.; Fardin, R.; and |and |Freeark, R. J.: Lower extremity thrombophlebitis in patients with femoral neck fractures. A venographic investigation and a review of the early and late significance of the findings. J. Trauma,8: 527-534, 1968.8527 1968 [PubMed][CrossRef]

Wood, E. H.; Prentice, C. R.; and |and |McNicol, G. P.: Association of fibrinogen-fibrin-related antigen (F.R.-antigen) with postoperative deep-vein thrombosis and systemic complications. Lancet,1: 166-169, 1972.1166 1972 [PubMed][CrossRef]

Topics

deep vein thrombosis ; fracture ; hospital admission

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WILLIAM F. HEFLEY, JR., CARL L. NELSON, CHERYL L. PUSKARICH-MAY; Effect of Delayed Admission to the Hospital on the Preoperative Prevalence of Deep-Vein Thrombosis Associated with Fractures about the Hip*. The Journal of Bone & Joint Surgery. 1996 Apr;78(4):581-3.

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