Priority 16 from the Complex Fractures PSP

UNCERTAINTY: What is the best strategy for preventing blood clots after complex fractures?  (JLA PSP Priority 16)
Overall ranking 16
JLA question ID 0105/16
Explanatory note Patients with complex fractures are at an increased risk of venous thrombo-embolism (VTE) (ie blood clots) whereby blood clots may form at peripheral sites and move in the circulation to block blood flow. In some cases, this may result in cardiac arrest and death.  

NG89 includes a review of 15 studies, 13 of which were randomised controlled trials. Where pharmacological or mechanical prophylaxis was compared with no prophylaxis, there were better outcomes in the group receiving an intervention. The NICE committee considered that the evidence sufficiently supported the use of Low Molecular Weight Heparin and Fondaparinux. The listed randomised controlled trial supports use of aspirin alone, however NICE committee felt inadequate evidence on bleeding risk and therefore this was listed as a research recommendation. There was a lack of evidence evaluating Direct Oral Anticoagulants in this review population.

A 2020 Randomised Controlled Trial linked here by Haac et al. found no evidence of superiority between Low Molecular Weight Heparin or Aspirin for VTE prevention in fracture patients. Non-pharmaceutical method of VTE prophylaxis exist and include patient hydration, early mobilisation, and compression stockings. 

NICE Guideline 89 Venous thromboembolism in over 16s: reducing the risk of hospital-acquired deep vein thrombosis or pulmonary embolism

Aspirin versus low-molecular-weight heparin for venous thromboembolism prophylaxis in orthopaedic trauma patients: A patient-centered randomized controlled trial

Health Research Classification System category Injuries and accidents
Extra information provided by this PSP
Original uncertainty examples If I will always have to wear compression stockings 
Submitted by 1 x Patient 
PSP information
PSP unique ID 0105
PSP name Complex Fractures
Total number of uncertainties identified by this PSP. 58  (To see a full list of all uncertainties identified, please see the detailed spreadsheet held on the JLA website)
Date of priority setting workshop 8th June 2021