DVT with Pulmonary Embolism in Patient with Grade 2 Compound Tibia Shaft Fracture- Treated with Thrombolysis and Use of Prophylactic IVC Filter: Case Report.

Introduction: Major orthopedic procedures place patients at risk for Deep venous thrombosis (DVT) and pulmonary embolism (PE). DVT has a 10-40% incidence after isolated fractures of the tibia and distal bones of the lower extremity. Diagnostic techniques are venous compression ultrasonography, venography, and pulmonary angiography. Prevention methods for venous thromboembolism (VTE) include mechanical prophylaxis and pharmacological prophylaxis. Inferior vena cava filter (IVCF) intercepts thrombus in inferior vena cava and prevents it from reaching the pulmonary artery.

Case Report: A 39-year-old female having compound Type 2 mid-shaft tibia fracture and operated with intramedullary nailing at a corporate hospital, Navi Mumbai in January 2024. Despite giving DVT prophylaxis, she developed shortness of breath on 3rd day. 2D echocardiogram (ECHO) showed dilated right atrium and right ventricular and computed tomography pulmonary angiography (CTPA) showed saddle embolism at the junction of pulmonary artery division. The cardiologist immediately advised intravenous (IV) thrombolysis (injection tenecteplase 30 mg stat) followed by IV anticoagulants (injection low molecular weight heparin 0.6) and oral (rivaroxaban 20 mg) for 15 days. However, she complained of high-grade fever, right leg persistent swelling, and per vaginal (PV) bleeding. Venous Doppler showed persistent thrombi. Hence oral rivaroxaban was stopped, and IVCF was inserted in February 2024 to prevent further embolization. After observing her menstrual cycles, she was resumed on oral rivaroxaban after 1 month. Follow-up after 3 months of surgery (April 2024) showed signs of healing of shaft tibia fracture. Follow-up after 3 months of IVCF placement (May 2024) showed no persistent thrombi in bilateral lower limb venous Doppler. Hence decision of F removal was made at 3 months.

Conclusion: Clinical evaluation of patients is important for the detection of DVT-PE. Complain of breathlessness on exertion suggested the diagnosis of PE, confirmed by 2D ECHO and CTPA, and immediately treated by the cardiac team with thrombolytics and anticoagulants. Since the patient developed bleeding PV, the insertion of an IVCF is the best option for treatment and prophylaxis of future VTE episodes.