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Potential for Thromboembolism after Fracture Treatment

Clinician's Brief (Capsule)

Orthopedics

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March 2014

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A spayed crossbreed (3 years of age) suffered a grade-I transverse fracture of the right humerus after vehicular trauma. Following open reduction and internal fracture fixation, the dog demonstrated weight-bearing lameness at discharge; it presented 4 days later with acute pain, nonweight bearing lameness, knuckling, coolness of the right thoracic limb, and absent digital pulses. Unfractionated heparin and clopidogrel were administered. Ultrasonography confirmed a thrombus in the right brachial artery. Within 48 hours, the patient was nonpainful, used the limb with moderate weight bearing, and was discharged on dalteparin SC and clopidogrel PO. Five weeks later, ultrasonography showed resolution of the thrombus and normal blood flow. Seven months after anticoagulant therapy, the patient demonstrated full mobility and resolution of signs.

Thromboembolic events are associated with increased mortality, morbidity, hospital stay, and cost. Hemostatic complications may be caused by dysfunction of Virchow’s triad: hypercoagulability, blood stasis, and endothelial injury. This patient likely developed the thrombus predominantly from blood stasis and endothelial injury from primary and secondary effects of trauma. Systemic thrombolytics, although administered in humans with acute thrombosis, are controversial because of inherent bleeding risks. There is currently no consensus in veterinary medicine on anticoagulant therapy. Thrombosis should be suspected in any dog with acute pain that does not resolve with appropriate treatment after severe trauma or fracture repair.

Commentary

In humans, excessive thrombin generation occurs after trauma, predisposing patients to venous thromboembolism; thus, anticoagulants are part of the therapeutic regimen. Veterinary clinicians should have an awareness of thromboembolism after fracture repair following traumatic injury and therapy with anticoagulants ± platelet function inhibitors (ie, clopidogrel), especially with an arterial thrombus, should be used if a thrombus has been identified.—Lisa Powell, DVM, DACVECC

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