The Risk of Venous Thromboembolism in Children After Trauma Is Greater Than We Think

Commentary On the basis of a database study, Mittal et al. found that the risk of venous thromboembolism (VTE) in children after the surgical treatment of lower-extremity fracture is greater than we may have suspected. They found those at highest risk to be those with fractures of the femur and pelvis. Yet, the incidence was still quite low for children with femoral fractures (0.5% in children, 2.5% in adolescents) and pelvic fractures (1.2% in children, 2.8% in adolescents). While these findings are of interest, 3 questions need to be explored with regard to pediatric patients: (1) What is the morbidity associated with VTE in pediatric patients? The consequences of VTE in children are unclear1. Our perceptions are largely based on the adult experience, with the feared complication of pulmonary embolism and perhaps even death. Yet it is unclear whether children are susceptible to severe pulmonary consequences or long-term sequelae or whether they simply clear the condition and “get over it.” Or is VTE something like asthma, which is extremely prevalent and can result in severe life-threatening consequences, but yet rarely interferes with our orthopaedic treatment? (2) What is the treatment of VTE in pediatric patients, and is it effective? It is unclear what treatments are needed or effective in children. Anticoagulant and thrombolytic drugs may have a role for adult patients with VTE. However, their effectiveness in children is largely untested and unproven. Intravascular procedures, such as catheter thrombolysis, thrombectomy, or the placement of filters, are largely untested in children2. VTE treatments in adults can result in serious side effects. It is not clear how they might affect children. (3) Is VTE prophylaxis warranted in pediatric patients? It is unclear whether prophylactic treatments are needed or effective in children and adolescents3. While there is little or no risk in the use of mechanical measures, such as compression stockings or external compression devices, anticoagulation treatments may result in considerable iatrogenic morbidity. The utility of prophylactic measures in children may be the most important subject for study in VTE. The authors have alerted us that the incidence of VTE in children is greater than we thought and suggest a call for action. But in the process, they have opened up a Pandora’s box of unanswered questions. Further study is needed, but it will be difficult to perform; even though VTE is more common than we thought, it is not so common as to make study easy. It is likely that the use of databases will be needed to garner enough patient data to find meaningful results.