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Pulmonary thromboembolism after operation for bilateral open distal radius fractures: a case report
BMC Research Notes volume 7, Article number: 36 (2014)
Pulmonary thromboembolism after upper extremity operation is rare. We report a patient with thromboembolism after debridement open reduction and internal fixation for bilateral open distal radius fractures.
The Japanese patient was an 80-year-old previously healthy female who was able to walk on her own. She fell down and was taken to our hospital. She was diagnosed with bilateral open distal radius fractures and we performed debridement open reduction and internal fixation on the same day. Although she could not walk and was depressed, she was discharged on the ninth postoperative day. However, on the eleventh postoperative day, she returned to our emergency department with complaints of dyspnea and cold sweat. Her serum D-dimer level was 19.0 μg/dl, troponin T was positive, and urgent contrast computed tomography scan of her thorax revealed thrombosis in the bilateral main pulmonary artery. She was diagnosed with pulmonary thromboembolism and admitted to our hospital again. On the second admission, although she had breathing problems, she did not require a respirator. Oxygen was supplied as well as anticoagulants. On the seventh day after being diagnosed with embolism, thrombosis in the bilateral main pulmonary arteries had disappeared.
The patient did not have any “strong” risk factors as reported in the Japanese Orthopedic Association Clinical Practice Guideline on the Prevention of Venous Thromboembolism in Patients Undergoing Orthopedic Treatments. In general, upper extremity operation carries a low risk for pulmonary thromboembolism. For patients with decreased activity of daily living and depression, we should consider postponing discharge and performing rehabilitation until activity of daily living is improved.
Pulmonary thromboembolism and deep vein thromboembolism are complications after orthopedic operations. Recently, some methods for prophylaxis have been reported [1–4]. Guidelines have been published for numerous countries and they indicate the importance of taking preventative measures for large joint operations, for example knee or hip joint operations (American College of Chest Physicians Evidence-Based Clinical Practice Guidelines (ACCP) ; Japanese Orthopaedic Association (JOA) ; and National Institute of Health and Clinical Excellence Guidelines (NICE) ). However, there is no consensus of prophylactic treatments for pulmonary thromboembolism after upper extremity operation. For patients who would undergo operations of the upper extremities and would be able to get out of bed and walk soon thereafter, no aggressive prophylactic treatments are recommended [5, 6].
In this case report, we present a patient who experienced pulmonary thromboembolism after operation for bilateral open distal radius fractures.
We report a case of an 80-year-old previously healthy Japanese female patient who was able to walk on her own. She fell down and was taken to our hospital. There were cut wounds measuring approximately 5 cm on the palmar side of both wrists (Figure 1A and B) and radiographs showed bilateral distal radius fractures. The right side was classified as A3 according to the Arbeitsgemeinschaft für Osteosynthesefragen (AO) classification and the left side was A1 (Figure 2A,B,C and D). She was diagnosed with bilateral open distal radius fractures and we performed debridement open reduction and internal fixation on the same day.
We resected skin of the edges in the wounds and debrided the contaminated tissues in the wounds. Since contamination of bones was almost nonexistent, we performed osteosynthesis with volar locking plates (Figure 3A,B,C and D). No postoperative immobilization was prescribed and the patient was encouraged to use her upper limb immediately after the operation. Also, patient was allowed to get out of bed the day after the surgery. However, she was unwilling to leave her bed due to the three factors; depression, strong pain and her age.
On the eleventh postoperative day, she returned to our emergency department with complaints of dyspnea and cold sweat. Her serum D-dimer level was 19.0 μg/dl, troponin T was positive and urgent contrast computed tomography (CT) scan of her thorax revealed thrombosis in her bilateral main pulmonary arteries (Figure 4A). She was diagnosed with pulmonary thromboembolism and was immediately admitted.
Although she had breathing problems, she did not require a respirator. Oxygen was supplied as well as anticoagulants (urokinase, heparin). On the seventh day after the embolism was found, her condition in general became stable, and thrombosis in her bilateral main pulmonary arteries disappeared on CT scan (Figure 4B). She started taking oral administration of warfarin and the intravenous heparin therapy was stopped. Twelve months after the operation, there was no embolism relapsed and she had attained her original activities of daily life.
For patients who would undergo operations of the upper extremities and would be able to get out of bed and walk soon thereafter, no aggressive prophylactic treatment are recommended [5, 6]. Also, there are no common prophylactic guidelines for pulmonary thromboembolism after operations on upper extremity. The guidelines in other countries including the United States and the United Kingdom make no references on this issue [5, 7].
NICE, which are the guidelines for the United Kingdom, say that the following patients should be treated with anticoagulants: patients with active cancer or undergoing cancer treatment, age over 60 years, critical care admission, dehydration, known thrombophilias, obesity (body mass index over 30 kg/m2), one or more significant medical comorbidities (for example: heart disease; metabolic, endocrine or respiratory pathologies; acute infectious diseases; inflammatory conditions), personal history or first-degree relative with a history of venous thromboembolism, hormone replacement therapy, estrogen-containing contraceptive therapy, or varicose veins with phlebitis . However, the prophylactic treatment for thromboembolism has been differently conducted according to the doctor in charge.
We analyzed 8 reports of thromboembolism after operations on upper extremities (Table 1). These cases tended to occur after operation for trauma or for bilateral upper extremities [8–13]. There were 2 patients who had thrombophilia problems before operation [12, 14]. One of them had stopped the administration of warfarin and the other had essential thrombocythemia . In addition, the patients with injured or operated limbs required long-term fixation because thromboembolism in veins of the diseased limbs was found after shoulder  or remote skin flap operations .
Although our patient experienced bilateral trauma, she did not need fixation, she was allowed to perform range of motion exercises, and she was not confined to specific body positions. This point differs from the reports of Norwood et al. and Watanabe et al. [8, 13]. Moreover, our patient had no previous thrombophilia problems.
Our patient was not motivated to leave her bed after the operation even though she could walk on the operation day. As a result, she remained in bed until the ninth post-operative day. This is the reason why the pulmonary thromboembolism occurred. We believe she had difficulty of leaving her bed because of her age, pain, and anxiety. According to Nickinson et al. researchs on the occurrence of anxiety and depression after operation, they reported that elderly patients and women tended to experience depression after operation . Therefore, we should take depression into our consideration strongly after operations in elderly women. The patient mentioned in this report refused to leave her bed and was unwilling to ride in a wheelchair regardless of repeated admonitions from the doctors and nurses.
We believe it was insufficient to manage pain control by using non-steroidal anti-inflammatory drugs. Stronger medications such as opioids used after total knee arthroplasty  should have been administered. Insufficient pain control after operation might contribute to depression, therefore, we should consider using opioids under general conditions. Likewise, it is necessary for us to have a cooperation from exparts on depression for those experienced anxiety and depression.
The patient did not have any “strong” risk factors as reported in the Japanese Orthopedic Association Clinical Practice Guideline on the Prevention of Venous Thromboembolism in Patients Undergoing Orthopedic Treatments. In general, upper extremity operation carries a low risk for pulmonary thromboembolism. For patients with decreased activity of daily living (ADL) and depression after operation, we should consider postponing discharge and performing rehabilitation until their ADL is improved.
Written informed consent was obtained from both the patient and her daughter for publication of this case report and accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.
YI (first author) mainly wrote this manuscript and was an assistant of operative procedure. KN (corresponding author) mainly performed medical examinations and surgery for this patient. YS, KK and OO discussed and advised about the treatment for this patient. All authors read and approved the final manuscript.
American College of Chest Physicians Evidence-Based Clinical Practice Guidelines
Japanese orthopaedic association
National Institute of Health and Clinical Excellence Guidelines
Arbeitsgemeinschaft für Osteosynthesefragen
Activity of daily living.
Howard AW, Aaron SD: Low molecular weight heparin decreases proximal and distal deep venous thrombosis following total knee arthroplasty. A meta-analysis of randomized trials. Thromb Haemost. 1998, 79: 902-906.
Raskob G, Cohen AT, Eriksson BI, Puskas D, Shi M, Bocanegra T, Weitz JI: Oral direct factor Xa inhibition with edoxaban for thromboprophylaxis after elective total hip replacement. A randomised double-blind dose–response study. Thromb Haemost. 2010, 104: 642-649. 10.1160/TH10-02-0142.
Scurr JH, Machin SJ, Bailey-King S, Mackie IJ, McDonald S, Smith PD: Frequency and prevention of symptomless deep-vein thrombosis in long-haul flights: a randomised trial. Lancet. 2001, 357: 1485-1489. 10.1016/S0140-6736(00)04645-6.
Warwick D, Harrison J, Whitehouse S, Mitchelmore A, Thornton M: A randomised comparison of a foot pump and low-molecular-weight heparin in the prevention of deep-vein thrombosis after total knee replacement. J Bone Joint Surg Br. 2002, 84: 344-350. 10.1302/0301-620X.84B3.12372.
Kearon C, Akl EA, Comerota AJ, Prandoni P, Bounameaux H, Goldhaber SZ, Nelson ME, Wells PS, Gould MK, Dentali F, Crowther M, Kahn SR, American College of Chest Physicians: Antithrombotic therapy for VTE disease: Antithrombotic therapy and prevention of thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest. 2012, 141: e419S-494S.
Nakamura K, Tachibana S, Fuji T, Akagi M, Abe Y, Ikeda N, Ishii S, Kobayashi S, Sato T, Nakamura S, Higuchi F, Fujita S, Yanagimoto S: Japanese orthopaedic association (JOA) clinical practice guideline on the prevention of venous thromboembolism in patients undergoing orthopaedic treatments. 2008, Tokyo: Nankodo, In Japanese, 1
National Institute for Health and Clinical Excellence: Reducing the risk of venous thromboembolism (deep vein thrombosis and pulmonary embolism) in inpatients undergoing surgery. 2007, (NICE clinical guideline No. 46.) http://www.nice.org.uk/CG046 e-pub: http://www.nice.org.uk/nicemedia/live/13767/59720/59720.pdf
Norwood S, McAuley CE, Berne JD, Villarreal DH: Massive bilateral pulmonary embolus requiring pulmonary embolectomy in a low-risk trauma patient. J Trauma. 2004, 57: 416-10.1097/01.TA.0000082154.39923.8F.
Sasaki S: A case report of death by pulmonary embolism after finger fracture in 19 years old. Kossetsu. 2007, 29: 628-630. (in Japanese)
Starch DW, Clevenger CE, Slauterbeck JR: Thrombosis of the brachial vein and pulmonary embolism after subacromial decompression of the shoulder. Orthopedics. 2001, 24: 63-65.
Takizawa T, Akitsuki A, Yamazaki I, Matsunaga D, Kuraishi J: Pulmonary embolism after surgical treatment of Galeazzi fracture dislocation. A case report. Central Japan J Orthop Surg Traumatol. 2006, 49: 303-304. (in Japanese)
Teramoto H, Sumiyoshi M, Aitani T, Takagi T: A case of post operative pulmonary embolism associated with humeral surgical neck fracture. Central Japan J Orthop Surg Traumatol. 2004, 47: 807-808. (in Japanese)
Watanabe M, Hara K, Moriya K, Miura K: Pulmonary embolism after the operation of the upper extremity. Report of 2 cases. Kossetsu. 2012, 34: 409-412. in Japanese
Kim JD, Kim JT, Gan AW, Youn S, Kim YH: Pulmonary artery re-thrombosis following interruption of anti-thrombotic therapy for bilateral carpal tunnel release surgery: an update of current protocols. J Plast Reconstr Aesthet Surg. 2013, 66: 999-1002. 10.1016/j.bjps.2012.11.029.
Nickinson RS, Board TN, Kay PR: Post-operative anxiety and depression levels in orthopaedic surgery: a study of 56 patients undergoing hip or knee arthroplasty. J Eval Clin Pract. 2009, 15: 307-310. 10.1111/j.1365-2753.2008.01001.x.
Rabago D, Patterson JJ, Mundt M, Kijowski R, Grettie J, Segal NA, Zgierska A: Dextrose prolotherapy for knee osteoarthritis: a randomized controlled trial. Ann Fam Med. 2013, 11: 229-237. 10.1370/afm.1504.
The authors declare that it has no competing interests.
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Igeta, Y., Naito, K., Sugiyama, Y. et al. Pulmonary thromboembolism after operation for bilateral open distal radius fractures: a case report. BMC Res Notes 7, 36 (2014) doi:10.1186/1756-0500-7-36
- Distal radius fracture
- Pulmonary thromboembolism
- Activity of daily living