Major orthopaedic fractures are an independent risk factor for the development of venous thromboembolism (VTE), which are significant causes of preventable morbidity and mortality in trauma patients. Despite thromboprophylaxis, patients who sustain a pelvic or acetabular fracture (PA) continue to have high rates of VTE (12% incidence). Thrombelastography (TEG) is a whole-blood, point-of-care test which provides an overview of the clotting process. Maximal amplitude (MA), from TEG analysis, is the measure of clot strength and values ≥65mm have been used to quantify hypercoagulability and increased VTE risk. Therefore, the primary aim was to use serial TEG analysis to quantify the duration of hypercoagulability, following surgically treated PA fractures.

This is a single centre, prospective cohort study of adult patients 18 years or older with surgically treated PA fractures. Consecutive patients were enrolled from a Level I trauma centre and blood draws were taken over a 3-month follow-up period for serial TEG analysis. Hypercoagulability was defined as MA ≥65mm. Exclusion criteria: bleeding disorders, active malignancy, current therapeutic anticoagulation, burns (>20% of body surface) and currently, or expecting to become pregnant within study timeframe.

Serial TEG analysis was performed using a TEG6s hemostasis analyzer (Haemonetics Corp.) upon admission, pre-operatively, on post-operative day (POD) 1, 3, 5, 7 (or until discharged from hospital, whichever comes sooner), then in follow-up at 2-, 4-, 6-weeks and 3-months post-operatively. Patients received standardized thromboprophylaxis with low molecular weight heparin for 28 days post-operatively. VTE was defined as symptomatic DVT or PE, or asymptomatic proximal DVT, and all participants underwent a screening post-operative lower extremity Doppler ultrasound on POD3. Descriptive statistics were used to determine the association between VTE events and MA values. For the primary outcome measure, the difference between the MA threshold value (≥65mm) and serial MA measures, were compared using one-sided t-tests (α=0.05).

Twenty-eight patients (eight females, 29%) with a mean age of 48±18 years were included. Acetabular fractures were sustained by 13 patients (46%), pelvic fractures by 14 patients (50%), and one patient sustained both. On POD1, seven patients (25%) were hypercoagulable, with 21 patients (78%) being hypercoagulable by POD3, and 17 patients (85%) by POD5. The highest average MA values (71.7±3.9mm) occurred on POD7, where eight patients (89%) were hypercoagulable. At 2-weeks post-operatively, 16 patients (94%) were hypercoagulable, and at four weeks, when thromboprophylaxis was discontinued, six patients (40%) remained hypercoagulable. Hypercoagulability persisted for five patients (25%) at 6-weeks and for two patients (10%) by three months.

There were six objectively diagnosed VTE events (21.4%), five were symptomatic, with a mean MA value of 69.3mm±4.3mm at the time of diagnosis. Of the VTE events, four occurred in participants with acetabular fractures (three male, 75%) and two in those with pelvic fractures (both males).

At 4-weeks post-operatively, when thromboprophylaxis is discontinued, 40% of patients remained hypercoagulable and likely at increased risk for VTE. At 3-months post-operatively, 10% of the cohort continued to be hypercoagulable. Serial TEG analysis warrants further study to help predict VTE risk and to inform clinical recommendations following PA fractures.

Background

Malnutrition has been suggested to increase the risk of falls in frail elderly. It has been hypothesised that elderly, orthopaedic trauma patients may be malnourished. We conducted an observational study to identify if this was the case.

The purpose of this study was to determine the normal angle of rotation of the axis of each finger using digital image analysis, whether the rotation of the digits is symmetrical in the two hands of an individual, and the reliability of this method.

Standardised digital photographic images were taken of thirty healthy volunteers. The palm of each hand was placed on a flat bench top with their fingers held in extension and adducted, to give an end-on image of all four fingers. Three independent observers analysed the images using Adobe Photoshop software. The rotational angle of each finger was defined as the angle created by a straight line connecting the radial and ulnar border of the nail plate and the bench top horizon.

The three observers showed Inter-Rater Reliability of 92%. The mean angles of rotation were: Index 13°, Middle 10°, Ring 5°, Little 12°. The differences in angle of rotation of the index and middle finger between the left and right hand were statistically significant (p=0.003, and p=0.002 respectively), demonstrating asymmetry between the two sides. The differences in angle of rotation of the ring and little finger of the left and right hand were not significantly significant (p= 0.312 and p=0.716 respectively).

In conclusion, symmetry was seen in the little and ring but not in the index and middle fingers. Digital image analysis provides a non-invasive and reproducible method of quantifying the rotation of normal fingers and may be of use as a diagnostic tool in the assessment and management of hand injuries.