BMJ  2006;333:147 (15 July), doi:10.1136/bmj.333.7559.147-c

Letter

Hip fracture: heparin is for thromboembolic prophylaxis

EDITOR—Thromboembolic prophylaxis for hip fracture is contentious, as Parker and Johansen state in their review of hip fracture.¹ Well might eyebrows be raised, however, by their failure to recommend any form of low molecular weight heparin thromboprophylaxis contrary to the latest American and British guidelines.² The current debate, driven by epidemiological data and recent clinical trials, is not the benefit of low molecular weight heparin preparations at proved doses but the likely inadequacy of typical courses of five to 10 days compared with longer and more inconvenient courses of 28 days or more.³

The authors further seem to imply that with heparin it is best to give nothing because of the risk of bleeding complications. Their referenced 2002 Cochrane review states there is a lack of power to identify outcomes of clinical importance apart from a reduction in deep vein thrombosis. There are currently concerns about wound infection rates in patients taking low molecular weight heparin,⁴ but no reason to be concerned about bleeding complications in the context of the entire evidence base and correctly timed thromboprophylaxis doses of heparin, taking into account spinal anaesthesia. Given that clinicians tend to undertreat with anticoagulants patients such as the elderly at highest risk of thromboembolism and overtreat patients at low risk such as the fit young coming in for elective operations,⁵ the article does a gross disservice to an important issue.

Failing to make recommendations consistent with international guidelines in a review article on managing hip fracture could unnecessarily help perpetuate the undertreatment of one of the groups of patients at highest risk of thrombotic complications.

Queen Elizabeth, The Queen Mother Hospital, Margate, Kent CT9 4AN mljenkinson{at}ekht.nhs.uk

---

Competing interests: None declared.

References

1. Parker M. Johansen A. Hip fracture. BMJ 2006;333: 27-30. (1 July.)[Free Full Text]
2. Baglin T, Barrowcliffe TW, Cohen A, Greaves M. British Committee for Standards in Haematology. Guidelines on the use and monitoring of heparin. Br J Haematol 2006;133: 19-34.[CrossRef][ISI][Medline]
3. Arcelus JI, Kudrna JC, Caprini JA. Venous thromboembolism following major orthopedic surgery: what is the risk after discharge? Orthopedics 2006;29: 506-16.[ISI][Medline]
4. Sanchez-Ballester J, Smith M, Hassan K, Kershaw S, Elsworth CS, Jacobs L. Wound infection in the management of hip fractures: a comparison between lowmolecular weight heparin and mechanical prophylaxis. Acta Orthop Belg 2005;71: 55-9.[Medline]
5. Deheinzelin D, Braga AL, Martins LC, Martins MA, Hernandez A, Yoshida WB, et al. Incorrect use of thromboprophylaxis for venous thromboembolism in medical and surgical patients: results of a multicentric, observational and cross-sectional study in Brazil. J Thromb Haemost 2006;4: 1266-70.[CrossRef][ISI][Medline]

CiteULike    Complore    Connotea    Del.icio.us    Digg    Reddit    Technorati    What's this?

Related Article

Hip fracture

Martyn Parker and Antony Johansen
BMJ 2006 333: 27-30. [Extract] [Full Text] [PDF]