Venous Thromboembolism in Patients Discharged From the Emergency Department With Ankle Fractures: A Population-Based Cohort Study - 20/12/21
, Clare L. Atzema, MD, MSc b, c, d, Rinku Sutradhar, PhD c, e, Karl Everett, MSc c, Daniel Horner, MBBS, MD f, g, Cameron Thompson, MSc a, John Theodoropoulos, MD, MSc h, Bjug Borgundvaag, PhD, MD a, i, Shelley L. McLeod, MSc, PhD a, j, Kerstin de Wit, MD, MSc kAbstract |
Study objective |
Temporary lower limb immobilization may be a risk for venous thromboembolism. The purpose of this study was to examine the 90-day incidence of venous thromboembolism among patients discharged from an emergency department (ED) with ankle fractures requiring temporary immobilization. Secondary objectives were to examine individual factors associated with venous thromboembolism in this population and to compare the risk of venous thromboembolism in patients with ankle fractures against a priori-selected control groups.
Methods |
This was a retrospective cohort study using province-wide health datasets from Ontario, Canada. We included patients aged 16 years and older discharged from an ED between 2013 and 2018 with closed ankle fractures requiring temporary immobilization. We estimated 90-day incidence of venous thromboembolism after ankle fracture. A Cox proportional hazards model was used to evaluate risk factors associated with venous thromboembolism, censoring at 90 days or death. Patients with ankle fractures were then propensity score matched to 2 control groups: patients discharged with injuries not requiring lower limb immobilization (ie, finger wounds and wrist fractures) to compare relative hazard of venous thromboembolism.
Results |
There were 86,081 eligible patients with ankle fractures. Incidence of venous thromboembolism within 90 days was 1.3%. Factors associated with venous thromboembolism were older age (hazard ratio [HR]: 1.18; 95% confidence interval [CI]: 1.00 to 1.39), venous thromboembolism or superficial venous thrombosis history (HR: 5.18; 95% CI: 4.33 to 6.20), recent hospital admission (HR: 1.33; 95% CI: 1.05 to 1.68), recent nonankle fracture surgery (HR: 1.58; 95% CI: 1.30 to 1.93), and subsequent surgery for ankle fracture (HR: 1.80; 95% CI: 1.48 to 2.20). In the matched cohort, patients with ankle fractures had an increased hazard of venous thromboembolism compared to matched controls with finger wounds (HR: 6.31; 95% CI: 5.30 to 7.52) and wrist fractures (HR: 5.68; 95% CI: 4.71 to 6.85).
Conclusion |
The 90-day incidence of venous thromboembolism among patients discharged from the ED with ankle fractures requiring immobilization was 1.3%. These patients had a 5.7- to 6.3-fold increased hazard compared to matched controls. Certain patients immobilized for ankle fractures are at higher risk of venous thromboembolism, and this should be recognized by emergency physicians.
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| Please see page 36 for the Editor’s Capsule Summary of this article. |
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| Supervising editor: Timothy F. Platts-Mills, MD, MSc. Specific detailed information about possible conflict of interest for individual editors is available at editors. |
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| Author contributions: KG, CLA, BB, SLM, JT, and KdW conceptualized the study. KG, CLA, RS, and KdW developed the data creation plan and analysis plan. KE conducted the analysis. CT conducted the validation study. All authors contributed to data interpretation. KG, KdW, and DH created the first draft of the manuscript, and all authors provided critical feedback and edits for the final manuscript. KG takes responsibility for the integrity of the work as a whole. |
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| All authors attest to meeting the four ICMJE.org authorship criteria: (1) Substantial contributions to the conception or design of the work; or the acquisition, analysis, or interpretation of data for the work; AND (2) Drafting the work or revising it critically for important intellectual content; AND (3) Final approval of the version to be published; AND (4) Agreement to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. |
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| Funding and support: By Annals policy, all authors are required to disclose any and all commercial, financial, and other relationships in any way related to the subject of this article as per ICMJE conflict of interest guidelines (seewww.icmje.org). This study received funding support from a CanVECTOR Research Start-Up Award. Dr Grewal was supported by a CanVECTOR fellowship award; the CanVECTOR Network receives grant funding from the Canadian Institutes of Health Research (Funding Reference: CDT-142654). The funding agreement ensured the investigators maintained control over the study design, methods, and interpretation of the results. Dr Atzema was supported by a Mid-Career Investigator Awards from the Heart and Stroke Foundation, Sunnybrook Health Sciences Centre, and ICES. Dr de Wit was supported by grants from Hamilton Health Sciences Foundation and the PSI Foundation. |
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| This study was supported by ICES, which is funded by an annual grant from the Ontario Ministry of Health (MOH) and the Ministry of Long-Term Care (MLTC). Parts of this material are based on data and information compiled and provided by the MOH, MLTC, Canadian Institute for Health Information (CIHI), and Cancer Care Ontario (CCO). The analyses, conclusions, opinions, and statements expressed herein are solely those of the authors and do not reflect those of the funding or data sources; no endorsement is intended or should be inferred. We thank IQVIA Solutions Canada Inc for use of their Drug Information File. |
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| The data set from this study is held securely in coded form at ICES. While data sharing agreements prohibit ICES from making the data set publicly available, access may be granted to those who meet prespecified criteria for confidential access, available at DAS. The full data set creation plan and underlying analytic code are available from the authors on request, understanding that the computer programs may rely on coding templates or macros that are unique to ICES and therefore are inaccessible or may require modification. |
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