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Three Part Question

In [patients with isolated upper extremity injury] does [the use of temporary immobilisation via plaster cast/sling] increase the risk of [subsequent venous thromboembolic events within short term follow up]?

Clinical Scenario

A 25 year old female presents to your department having fallen off her bike and is diagnosed with an undisplaced midshaft humeral fracture by a junior collegue. Plaster immobilisation and fracture clinic follow up in one week is arranged. It is likely that the arm will be immobilised for at least four weeks.

There is no relevant medical history of note, however there is a family history of thromboembolic events, and the patient is on the oral contraceptive pill.

You wonder if upper limb immobilisation carries similar risks to lower regarding venous thromboembolic disease.

Search Strategy

Cochrane database and MEDLINE/EMBASE were searched to the week ending Friday 13th May 2011, using NHS evidence as an interface.

[(exp IMMOBILIZATION/) OR (exp CASTS, SURGICAL/) OR (exp SPLINTS/) OR (sling.ti,ab) OR (cast*.ti,ab) OR (immobilisation.ti,ab) OR (immobilisation.mp) OR (plaster AND of AND paris.mp) OR (back-slab.ti/ab)] AND[ (exp UPPER EXTREMITY/) OR (upper AND extremity.ti,ab) OR (upper AND extremity.ti,mp) OR (arm.ti,ab) OR (exp ARM INJURIES/) OR (exp ARM/) OR (exp WRIST/) OR (exp WRIST INJURIES/) OR (exp SHOULDER/) OR (exp HAND/) or (exp HAND INJURIES/) OR (exp FINGER/) OR (exp FINGER INJURIES/) OR (exp SHOULDER DISLOCATION/) OR (exp FRACTURES, BONE/)] AND [(exp VENOUS THROMBOEMBOLISM/) OR (exp THROMBOEMBOLISM/) OR (exp PULMONARY EMBOLISM/) OR (exp DEATH, SUDDEN/) OR (exp VENOUS THROMBOSIS) OR (exp THROMBOPHLEBITIS/) OR (VTE.ti,ab) OR (deep AND vein AND thrombosis.mp) OR (Pulmonary AND embolism.mp) OR (thrombo*.ti,ab) OR (exp RISK FACTORS/) OR (*UPPER EXTREMITY DEEP VEIN THROMBOSIS/co) OR (*UPPER EXTREMITY DEEP VEIN THROMBOSIS/di)]

Search Outcome

104 papers were identified and reviewed by title and abstract. Only 4 of these papers were suitable to the three part question. These papers are therefore included in the table of evidence below:

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
Blom JW, Doggen CJ, Osanto S, Rosendaal FR. November 2005 The Netherlands	179 Patients presenting between March 1999 and September 2003 with a first upper limb DVT. A comprehensive questionnaire was given to each individual in order to identify possible risk factors. This data was compared to that obtained from approx 2400 control subjects	Population-based case-control study (Level of evidence 3b)	Adjusted Odds ratio for upper limb DVT in those with recent plaster cast immobilisation	3/79 vs 7/2398 = 7(95% CI 1.7 to 29.5)	Relatively small number of cases. In addition, the study recruits participants from anticoagulant centres. Finally the study only includes the use of plaster casts as "immobilisation".
Martinelli I, Battaglioli T, Bucciarelli P, Passamonti SM, Mannucci PM. August 2004 Italy	115 Patients presenting for thrombophilia screening after an episode of upper-extremity DVT.	Retrospective cohort study (level of evidence 2b)	No. of individuals with documented upper limb immobilisation prior to an upper limb DVT	0%	The patients were recruited from a centre for thrombophilia screening, perhaps resulting in some bias in the population represented in this study. Also this is a relatively small study (115) involving only one centre.
			Patients with preceeding upper limb trauma	4%
Marinella et al 2000 USA	90 adult patients with Deep Vein Thrombosis (DVT) of the internal jugular, subclavian, axillary, or brachial vein over a 5-year period.	Retrospective observational cohort study in a large urban teaching hospital (level of evidence 2b)	Prevalence of most common underlying risk factors for upper extremity DVT	Central Venous Catheter (CVC) 72%, Infection 28%, Extrathoracic malignancy 22%, and recent surgery 21%	Retrospective study of a small cohort. In addition, as it is a retrospective study, it is differcult to know whether patients had underlying hypercoagulable states e.g. factor V leiden mutation as most patients were not evaluated for such conditions.
Spencer et al 2007 USA and Canada	483 adult patients with validated acute Deep Vein Thrombosis (DVT), 14% of whom (69 patients) were diagnosed with upper extremity DVT.	Retrospective observational cohort study (Level of evidence 2b)	upper extremity DVT risk factors (%) (n=69)	Central Venous Catheter (CVT) 62.3%, Surgery within the 3 months prior to DVT diagnosis 48.5%, Fracture within 3 months of DVT diagnosis 15.9%	A small sample size. The medical record limits the information available on patient medical history and clinical characteristics.

Comment(s)

Injuries of the upper limb commonly present to the Emergency Department and are often treated by immobilisation. Immobilisation is a well known risk factor for thrombosis formation. It is reasonable to assume that this local risk is present also in the case of upper limb trauma and immobilisation. Independent risk factors for Deep Vein Thrombosis (DVT) are well described and, for the lower limb, include immobilisation in plaster cast. Upper extremity DVT (UEDVT) is independently associated mainly with Central Venous Catheter presence and cancer [1]. At present, there is little evidence in the literature to suggest that immobilisation of the upper limb is a major risk factor for thrombosis formation. Recent major surgery is documented as a risk factor, perhaps because of the subsequent hypercoagulable state or direct endothelial injury. However, there are very few reported cases of upper limb trauma and subsequent immobilsation that result in proximal thrombosis. There have been no studies assessing the prevalence of UEDVT in ambulatory patients with isolated limb trauma. Although the link between lower limb immobilisation and local Venous Thromboembolism (VTE) is well established, current evidence does not support a clear association with upper limb disease.

Clinical Bottom Line

There is no convincing current evidence to suggest that temporary immobilisation for upper limb trauma is a strong independent risk factor for UEDVT.

Level of Evidence

Level 2 - Studies considered were neither 1 or 3.

References

1. Blom JW, Doggen CJ, Osanto S, Rosendaal FR. Old and new risk factors for upper extremity deep venous thrombosis. J Thromb Haemost November 2005, 3(11):2471-8.
2. Martinelli I, Battaglioli T, Bucciarelli P, Passamonti SM, Mannucci PM. Risk factors and recurrence rate of primary deep vein thrombosis of the upper extremities. Circulation 2004;110:566-570
3. Marinella, MA. Kathula, SA. Markert, RJ. Spectrum of upper-extremity deep venous thrombosis in a community teaching hospital Heart Lung 2000; 29 (2):113-117
4. Spencer, FA. Emery, C. Lessard, D. Goldberg, R. Upper extremity Deep Vein Thrombosis: A Community-Based Perspective Am J Med 2007; 120 (8): 678-684.
5. Flinterman LE, van der Meer FJM, Rosendaal FR and Doggen CM. Current perspective of venous thrombosis in the upper extremity Journal of Thrombosis and Haemostasis 2008;6:1262-1266