How to manage a patient with a proximal humeral fracture on aspirin (acetylsalicylic acid) and clopidogrel, undergoing operative management?

Management of Proximal Humeral Fracture Surgery in Patients on Dual Antiplatelet Therapy

Continue aspirin throughout the perioperative period and proceed with surgery without stopping clopidogrel, as the risk of coronary thrombosis from antiplatelet withdrawal far exceeds the risk of surgical bleeding in proximal humeral fracture repair.

Critical First Step: Assess Cardiac Risk

Before making any antiplatelet management decisions, you must determine why this patient is on dual antiplatelet therapy:

• If the patient has coronary stents (especially drug-eluting stents placed <6-12 months ago): This represents a major thrombotic risk and clopidogrel must NOT be stopped 1
• If the patient has recent acute coronary syndrome or unstable angina: Aspirin and clopidogrel should both be continued 1
• If dual antiplatelet therapy is for secondary cardiovascular prevention without recent stenting: You have slightly more flexibility, but aspirin should still be maintained 1

Contact cardiology immediately if coronary stents are present to clarify timing and thrombotic risk stratification 1.

Recommended Antiplatelet Management Strategy

Aspirin Management

• Continue aspirin throughout the perioperative period at the current dose (up to 300 mg/day) 1
• Do not reduce the dosage for surgery 1
• Aspirin may only be withheld if there are NO indications for unstable angina or recent/frequent transient ischemic attacks 1

Clopidogrel Management

The key decision point is hemorrhagic risk classification of proximal humeral fracture surgery:

Proximal humeral fracture surgery (ORIF or arthroplasty) should be classified as intermediate hemorrhagic risk - the procedure can proceed on aspirin alone but involves moderate blood loss 1.

For patients with drug-eluting coronary stents:

• Maintain aspirin and stop clopidogrel 5 days before surgery if the stent was placed >6-12 months ago (moderate thrombotic risk) 1
• Do NOT stop clopidogrel if the stent was placed <6-12 months ago; proceed with surgery on both agents and expect marginally greater blood loss 1

For patients WITHOUT coronary stents:

• Clopidogrel is generally not stopped on admission for hip fracture surgery, and the same principle applies to proximal humeral fractures 1
• Surgery should not be delayed for clopidogrel washout 1

Surgical Timing and Execution

• Proceed with surgery without delay - do not postpone surgery waiting for antiplatelet washout 1
• Expect marginally greater blood loss (approximately 50 mL additional) if operating on clopidogrel 2
• Do NOT administer platelets prophylactically 1

Intraoperative Blood Loss Management

• Consider using tranexamic acid (TXA) to reduce blood loss - a single preoperative IV dose reduces total blood loss by approximately 90 mL in proximal humeral fracture surgery 2
• TXA decreased average total blood loss from 280 mL to 188 mL and reduced hemoglobin drop from -2.6 g/dL to -1.5 g/dL 2
• No complications associated with TXA use have been identified in this population 2

Anesthesia Considerations

Neuraxial anesthesia is possible when the patient is on aspirin alone 1. However, if clopidogrel is continued:

• Neuraxial blockade carries increased risk of epidural hematoma
• Consider general anesthesia or peripheral nerve blocks with caution
• The risk-benefit must be weighed carefully 1

Postoperative Antiplatelet Resumption

• Resume clopidogrel as soon as possible after surgery if it was stopped 1
• Some experts recommend a loading dose of at least 300 mg clopidogrel when resuming 1
• Continue aspirin throughout the postoperative period 1

Critical Pitfalls to Avoid

1. Never stop both aspirin and clopidogrel simultaneously in patients with coronary stents - this dramatically increases the risk of fatal stent thrombosis 1

2. Do not delay surgery waiting for antiplatelet washout - the mortality and morbidity from delaying fracture surgery exceeds the bleeding risk 1, 3

3. Do not use bridging therapy with heparin or LMWH when stopping antiplatelet agents - this is not indicated and increases bleeding risk 1

4. Do not substitute NSAIDs for antiplatelet agents perioperatively 1

Thromboprophylaxis Strategy

Despite being on antiplatelet therapy, patients still require venous thromboembolism prophylaxis:

• Aspirin alone provides adequate prophylaxis for proximal humeral fracture surgery 4
• Add pneumatic compression devices and early mobilization 4
• The incidence of DVT/PE is very low with this regimen in proximal humeral fracture surgery 4

Evidence Quality Note

The strongest guideline evidence addresses hip fracture surgery rather than proximal humeral fractures specifically 1. However, the principles of antiplatelet management apply equally, as both are orthopedic trauma procedures with intermediate bleeding risk. The 2018 French guidelines provide the most recent comprehensive framework for antiplatelet management in elective procedures 1, while the 2012 UK guidelines specifically address fracture surgery 1. Recent 2024 evidence confirms that discontinuation of aspirin and clopidogrel is not necessary prior to fracture surgery 3.