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Prophylaxis of venous thromboembolism in patients with lower limb plaster cast immobilisation
  1. E Brown, Foundation SHO Anaesthetics1,
  2. A Bleetman, Consultant Emergency Medicine2
  1. 1Royal Shrewsbury Hospital, Shrewsbury, UK
  2. 2Birmingham Heartlands Hospital, Birmingham, UK

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    Report by E Brown, Foundation SHO AnaestheticsRoyal Shrewsbury Hospital, Shrewsbury, UKChecked by A Bleetman, Consultant Emergency MedicineBirmingham Heartlands Hospital, Birmingham, UK

    A short cut review was carried out to establish whether patients with lower limb plaster cast immobilisation require venous thromboembolism (VTE) prophylaxis. Nineteen papers were found, of which four were relevant. The clinical bottom line is that for patients requiring lower limb plaster cast immobilisation for injury (fractures and soft tissue), there is evidence supporting the use of low molecular weight heparin (LMWH) as thromboprophylaxis for venous thromboembolism.

    Three part question

    In [patients with leg injuries requiring lower limb plaster cast immobilisation] is [low molecular weight heparin] necessary to [prevent venous thromboembolism]?

    Clinical scenario

    A 48-year-old man attends the emergency department with pain and swelling in his right calf after a game of squash. Clinical examination supported by ultrasound identifies a partial rupture of the Achilles tendon. You decide to treat him with an equinus plaster cast and arrange follow up. You wonder whether you should prescribe LMWH for venous thromboembolism prophylaxis for the duration of immobilisation in the cast.

    Search strategy

    Medline 1950 to week 4 August 2006 using the Dialog Datastar interface: ((casts) OR (casts-surgical#.de.) OR (plaster ADJ cast)) AND ((leg) OR (leg#.w..de.) OR (lower ADJ limb) OR (lower-extremity#.de.)) AND ((low ADJ molecular ADJ weight ADJ heparin) OR (heparin-low-molecular-weight#.de.) OR (lmw ADJ heparin) OR (lmwh) OR (thromboprophylaxis)) AND ((deep ADJ vein ADJ thrombosis) OR (venous-thrombosis#.de.) OR (venous ADJ thromboembolism) OR (thromboembolism#.w..de.) OR (pulmonary ADJ embolism) OR (pulmonary-embolism#.de.)) LIMITED to human AND English.

    EMBASE using the Dialog Datastar interface 1950 to week 4 August 2006: ((cast) OR (plaster ADJ cast) OR (plaster-cast#.de.)) AND ((leg) OR (leg#.w..de.) OR (lower ADJ limb) OR (lower ADJ extremity)) AND ((low ADJ molecular ADJ weight ADJ heparin) OR (low-molecular-weight-heparin#.de.) OR (lmw ADJ heparin) OR (lmwh) OR (thromboprophylaxis)) AND ((deep ADJ vein ADJ thrombosis) OR (deep-vein-thrombosis#.de.) OR (venous ADJ thromboembolism) OR (venous-thromboembolism#.de.) OR (pulmonary ADJ embolism) OR (lung-embolism#.de.)) LIMITED to human AND English

    Cochrane Issue 3, 2006. (‘cast’ and ‘venous thrombosis’ OR ‘venous thromboembolism’ OR ‘deep vein thrombosis’ OR ‘pulmonary embolism’)

    Search outcome

    A total of 17 papers were found, of which four were relevant (table 3).

    Table 3

    Comments

    Patients receiving subcutaneous injections on a daily basis need either to be trained to self-inject, to return to a health professional each day, or else remain an inpatient. The vast majority of patients in these studies were outpatients and coped well with self-injecting. Further research is needed to assess the cost-effectiveness of the increased resources needed to offer this treatment. No two studies used the same LMWH; the appropriate dose of any particular LMWH treatment has yet to be determined. There appears to be no significant increased risk of bleeding complications or other adverse reactions from LMWH for venous thromboembolism prophylaxis.

    CLINICAL BOTTOM LINE

    In patients requiring lower limb plaster cast immobilisation for injury (fractures and soft tissue), there is evidence supporting the use of LMWH as thromboprophylaxis for venous thromboembolism.

    Report by E Brown, Foundation SHO AnaestheticsRoyal Shrewsbury Hospital, Shrewsbury, UKChecked by A Bleetman, Consultant Emergency MedicineBirmingham Heartlands Hospital, Birmingham, UK

    References

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