Hrev_master [page 83] [Emergency Care Journal 2014; 10:4473] Fatal pulmonary embolism following ankle fracture in a 23-year-old man Stella Charitidou,1 Theodoros Aslanidis,2 Stellios Papalexandris3 1Emergency Department, General Hospital of Ptolemaida; 2Mobile Intensive Care Units, National Center of Emergency Care, Thessaloniki Department, Greece; 3Private Orthopedic Surgeon, Manchester, UK Abstract Patients with lower extremity injuries are at increased risk of venous thromboembolism. We report a case of fatal pulmonary embolism following a simple ankle fracture in a 23-year- old man. The diagnosis was confirmed post- mortem. The incidence of such complications and the importance of deep venous prophylaxis in such cases are discussed. Introduction In many countries, most stable ankle frac- tures are treated conservatively in a below- knee plaster cast. It has been suggested that this method of immobilization may increase the risk of deep-vein thrombosis (DVT) because of inactivation of the ankle pump.1 However, the real incidence of venous thorm- boembolism (VTE) and pulmonary embolism (PE) in patients with ankle fracture is still unknown, as the diagnosis includes various types of anatomic injuries, thus the literature reports a wide range of incidence for both VTE and PE. Fatal PE after simple fracture is con- sidered as rare. We report a case of a 23-year- old man, with an ankle fracture who suffered a massive PE which was confirmed post-mortem and carry out a mini literature review upon the subject. Case Report A 23-year-old man (height=179 cm, weight=83 kg, body mass index=25) was transported to Emergency Department (ED) within half hour after the onset of severe shortness of breath chest pain, discomfort and agitation. Past medical history included a con- servative treatment for minimal displaced left lateral malleolus fracture (Weber type B) 20 days before, which had been stabilized by a below-knee plaster of Paris caster. Medical reg- iment included only oral analgesics. Surgical and family history was non-contributory. He had no known drug allergies, no history of smoking, drug or alcohol abuse and no medical co-morbidities. On arrival, his Glasgow Coma Scale was E4/V5/M6, but 5 min later he col- lapsed in the ED. Immediate ventilation with 100% O2 was initiated, intubation was carried out and resuscitation according to Advance Life Support guidelines initiated. First recorder electrocardiography was asystoly and arterial blood gases revealed severe metabolic and respiratory acidosis (pH 6.57; PaCO2 153.6 mmHg; PaO2 17 mmHg; HCO- 3 13.6 mEq/L; basis excess -25.8; Na+ 143.6 mEq/L; K+ 5.38 mE/L; anion gap 34.1; Glu 702 mg/dL). During resuscitation efforts, the patient received tenecteplase 50 mg iv due to serious clinical suspicion of pulmonary embolism. Unfortunately, resuscitation was carried out for 60 min to no avail and the patient was pro- nounced dead. On post-mortem examination massive pulmonary embolism, with both macroscopic (in both pulmonary arteries) and microscopic foundlings (thrombi throughout the smaller arterial vessels in both lungs), con- firmed the clinical diagnosis. Discussion and mini review of the literature Foot and ankle trauma or lower extremity surgery may lead to a higher incidence of venous thromboembolism due to stasis, vascu- lar injury and immobilization. In addition, there are several other predisposing risk fac- tors that may also increase VTE incidence. They are principally classified into non-modifi- able (genetic: antithrombin, protein C and pro- tein S deficiencies, Factor V Leiden mutation, the prothrombin 20210A variant, higher D- dimer, etc.), modifiable (obesity consuming >1.5 servings of red and processed meat daily, homocysteine levels) and temporary (hospital- ization, oral contraceptive therapy, airline trav- el) factors.1,2 It is difficult to determine which patients require prophylaxis because little is known about the risk of DVT in patients with lower extremity injuries. Various studies report vari- ous incidences. SooHoo et al.3 reported PE rate of 0.34% (DVT rate not reported), Mizel et al.4 reported PE rate of 0.15% and DVT rate of 0.22%, Hanslow et al.5 higher rate of both PE (1.3%) and DVT (4%) – yet their study includ- ed trauma patients –, Lipidus et al.6 and Jorgensen et al.7 found even higher rates of DVT (17 and 28% respectively), probably because they examined asymptomatic VTE and performed venography in all patients. Moreover, the second study did not clarify the nature of the plaster cast (above- or below- knee) and included patients with different injuries. A fact that may also bias the inci- dence of DVT. In another trial, Patil et al.8 reported 5% of non-clinical DVT and zero cases of PE after assessment of 100 cases of isolated fractures of the ankle treated in a below-knee cast. Finally, in a large study of 4271 patients, Kavanagh et al.9 reported the rate of sympto- matic VTE in patients with isolated ankle frac- tures to be relatively low with a DVT rate of 0.29%, a PE of 0.36% and a combined VTE rate of 0.54%. Numerous case reports of fatal PE are also found in the literature.10,11 The current recommendation from the American College of Chest Surgeons is that thromboprophylaxis is not recommended for isolated injuries below the knee.12 Considering the low incidence of symptomatic DVT and PE found in the litera- ture and the relatively high cost of the routine prophylaxis strategy, these recommendations appear to be appropriate. Yet, cases like those aforementioned show that this policy may be debatable. We need large scale studies to really determine if the current guidelines need mod- ifications and to what extent. Conclusions Routine pharmacological prophylaxis to patients requiring prolonged immobilization Emergency Care Journal 2014; volume 10:4473 Correspondence: Theodoros Aslanidis, Mobile Intensive Care Units, National Center of Emergency Care, Thessaloniki Department, 54633 Thessaloniki, Greece. Tel. +30.697.2477166. E-mail: thaslan@hotmail.com Key words: pulmonary embolism, thromboembol- ic disease, ankle fracture. Contributions: SC contributed to the manage- ment and recording of the case; SP and TA reviewed the literature; TA drafted the manu- script. All authors read and agreed to the final version of this manuscript. Conflict of interests: the authors declare no potential conflict of interests. Received for publication: 29 June 2014. Revision received: 17 August 2014. Accepted for publication: 18 August 2014. This work is licensed under a Creative Commons Attribution 3.0 License (by-nc 3.0). ©Copyright S. Charitidou et al., 2014 Licensee PAGEPress, Italy Emergency Care Journal 2014; 10:4473 doi:10.4081/ecj.2014.4473 Non co mmerc ial us e o nly [Emergency Care Journal 2014; 10:4473] [page 84] in a cast rather than the current practice of selective use of prophylaxis in high-risk patients is debatable. Cases of fatal pulmonary embolism in otherwise healthy low-risk patients prove that larger studies need to be carried out to come to a definite conclusion. References 1. Baglin T, Luddington R, Brown K, Baglin C. Incidence of recurrent venous throm- boembolism in relation to clinical and thrombophilic risk factors: prospective cohort study. Lancet 2003;362:523-6. 2. Cushman M. Epidemiology and risk factors for venous thrombosis. Semin Hematol 2007;44:62-9. 3. SooHoo NF, Krenek L, Eagan MJ, et al. complication rates following open reduc- tion and internal fixation of ankle frac- tures. J Bone Joint Surg 2009;91:1042-9. 4. Mizel MS, Temple H, Michelson JD, et al. Thromboembolism after foot and ankle surgery: a multicenter study. Clin Orthop Relat R 1998;348:180-5. 5. Hanslow SS, Grujiec L, Slater HK, Chen D. Thromboembolic disease after foot and ankle surgery. Foot Ankle Int 2006;27:693- 5. 6. Lipidus LJ, Ponzer S, Elvin A, et al. Prolonged thromboprophylaxis with dal- teparin during immobilization after ankle fracture surgery. Acta Orthop 2007;78:528- 35. 7. Jorgensen PS, Warming T, Hansen K, et al. Low molecular weight heparin (innohep) as thromboprophylaxis in outpatients with a plaster cast: a venographic controlled study. J Thromb Res 2002;105:477-80. 8. Patil S, Gandhi J, Curzon I, Hui ACW. Incidence of deep-vein thrombosis in patients with fractures of the ankle treated in a plaster cast. J Bone Joint Surg Br 2007;89:1340-3. 9. Kavanagh M, Funahashi T, Maletis G, et al. Incidence of symptomatic venous throm- boembolism after operative and non-oper- ative ankle fractures. 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