Deep venous thrombosis (DVT) has become the bane of trauma professionals over the past 15+ years. We agonize about how to screen properly, the best ways to prevent, and why it has become such a problem. It’s fairly clear that clot in the veins of the thighs and higher have significant potential to cause major problems, specifically pulmonary embolism (PE).

But what about below the knee DVT? For a long time, we were not as concerned because it was not clear that it actually caused significant complications. I wrote about a study from OHSU last year that addressed this. Now, a recent study published from Scripps Hospital in San Diego confirms the answer to the question.

All trauma patients who were screened for DVT by duplex ultrasound over a 5 ½ year period were enrolled in a retrospective study of the progression and/or complications of this diagnosis. Patients who were at bed rest for 72 hours or who were considered at moderate or higher risk for DVT by American College of Chest Physicians guidelines were screened. Ward patients were screened by duplex weekly, and ICU patients were screened twice a week.

Here are the factoids:

• Nearly 3,000 of over 11,000 trauma patients were screened (25%)
• 251 (9%) had DVT or DVT+PE
• It took an average of 6 days for DVT to appear, and 9 days for PE
• Two thirds had below knee DVT, one third had above knee disease
• 4.4% of below knee DVT developed PE
• Below knee DVT progressed to above the knee in 13% of patients
• 86% of above knee clot was treated with anticoagulation vs only 24% with below knee DVT
• 64% of the patients who developed PE were not receiving prophylaxis

Bottom line: Below knee DVT is more significant than we thought, frequently progressing above the knee or throwing off pulmonary emboli. Duplex ultrasound needs to be performed from groin to ankle in at risk patients according to a protocol determined by your hospital. As for what to do when you find below the knee clot, the answer is not yet clear. If the patient has not been receiving chemical prophylaxis, they should at least be started. If they have been receiving prophyaxis, a change to therapeutic dosing is probably warranted. 

Related posts:

• Above knee vs below knee DVT
• Does interrupting DVT prophylaxis increase risk?
• DVT caused by microparticles?
• Enoxaparin and pregnancy

Reference: Below-knee deep vein thrombosis: An opportunity to prevent pulmonary embolism? J Trauma 77(3):459-463, 2014.

Our population is aging, and falls continue to be a leading cause of injury and morbidity in the elderly. Unfortunately, many elders have significant medical conditions that make them more likely to suffer unfortunate complications from their injuries and the procedures that repair them.

More and more hospitals around the world are applying a more multidisciplinary approach than the traditional model. One example is the Medical Orthopaedic Trauma Service (MOTS) at New York-Presbyterian Hospital/Weill Cornell Medical Center. Any elderly patient who has suffered a fracture is seen in the ED by both an emergency physician and a hospitalist from the MOTS team. Once in the hospital, the hospitalist and orthopaedic surgeon try to determine the reason for the fall, assess for risk factors such as osteoporosis, provide comprehensive medical management, provide pain control, and of course, fix the fracture. 

This medical center published a paper looking at their success with this model. They retrospectively reviewed 306 patients with femur fractures involving the greater trochanter. They looked at complications, length of stay, readmission rate and post-discharge mortality. No change in length of stay was noted, but there were significantly fewer complications, specifically catheter associated urinary tract infections and arrhythmias. The readmission rate was somewhat shorter in the MOTS group, but did not quite achieve significance with regression analysis.

Bottom line: This type of multidisciplinary approach to these fragile patients makes sense. Hospitalists, especially those with geriatric experience, can have a significant impact on the safety and outcomes of these patients. But even beyond this, all trauma professionals need to look for and correct the reasons for the fall, not just fix the bones and send our elders home. This responsibility starts in the field with prehospital providers, and continues with hospital through the entire inpatient stay.

Related post:

• Consequences of falls in the elderly

Reference: The medical orthopaedic service (MOTS): an innovative multidisciplinary team model that decreases in-hospital complications in patients with hip fractures. J Orthopaedic Trauma 26(6):379-383, 2012.

The August newsletter is now available! Click the image below or the link at the bottom to download. This month’s topic is Potpourri.

In this issue you’ll find articles on:

• An instant hemoglobin monitor
• Don’t ignore the naughty bits
• The referral hospital trauma rule
• The dogma of putting chest tubes to suction
• Small hospital, unstable patient
• How to lose a bet and still win!

Subscribers received the newsletter first last weekend. If you want to subscribe (and download back issues), click here.

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