Early deep vein thrombosis in patients admitted with fracture femur in Kenyatta National Hospital

Abstract

Fractures of the femur constitute a significant disease burden at KNH with approximately 13 patients needing admission each week. In the year 2016 a total of 625 patients were admitted to KNH with fractures of the femur. Deep venous thrombosis and pulmonary embolism are serious complications that can occur in the early period following fractures of the femur1,2, and pulmonary embolism has been shown to be third most common cause of death in patients surviving the first 24 hours following trauma3. Surgical intervention within 24 hours significantly reduces the mortality from pulmonary embolism4. However the majority patients with fracture femur seen at KNH are initially managed on traction while waiting to go to theatre for definitive management. This leads to prolonged immobilization. No study has been done to assess the incidence of early DVT in fracture femur. There are currently no protocols at Kenyatta National Hospital with regards to prevention of DVT in fracture femur. This study sought to establish the incidence of early DVT following admission in patients with fracture femur and the frequency and methods of prophylaxis commonly used in KNH in order to better inform policy and possible protocols for the management of DVT in KNH. Objective: To determine the incidence of early DVT in patients with fracture femur at KNH. Design: Prospective observational study. Setting: Accident and Emergency department, orthopedic wards Kenyatta National Hospital. Patient and methods: The study involved patients aged 18 years and above admitted in the orthopedic wards at KNH through A & E department with fracture femur. The patients were recruited using simple random sampling as they were seen at the Accident and Emergency

department. Patient demographics were recorded after consenting for the study. A total of 50 patients were recruited into the study. The patients were followed up for one week for symptoms of DVT and on day 7 following the fracture an ultrasound examination was done to look for the presence of DVT both in the injured and uninjured limb. The ultrasound was performed by two different radiographers in order to improve accuracy of the findings. Clear documentation of the presence or absence of clinical signs and symptoms was made and each patient was scored according to the modified well’s score. The surgeons in the wards were informed of any patient found to have DVT for further treatment. Results: A total of 50 patients were recruited into the study over a two month period. The mean age of the patients was 37 years (SD ± 14) with an age range between 18 and 88 years. There were 15 (30%) patients aged 18-29 years and 18 (36%) patients between 30 and 39 years. Males accounted for 68% of the patients with femoral fractures giving a Male-to-Female ratio of 2: 1. There were a total of four cases of DVT found corresponding to a prevalence of 8% and an incidence of 1.1 per 100 patient days of observation. There was a significant association between increasing patient age and DVT (p = 0.016). The prevalence of DVT in patients aged 60 years and above was 50% compared to 11.1% in 30-39 year olds while no DVT cases were reported outside these age groups. The prevalence of DVT in male (8.8%) and female (6.3%) patients was not significantly different (p = 0.754). There were no cases of pulmonary embolism observed during the study period. Conclusion and recommendations During the course of the study patients who were elderly patients and patients with proximal fracture femur were found to have DVT. Given the possible life threatening complications such as pulmonary embolism prophylaxis against DVT should be considered in patients with fractures of the femur.