What is the operative plan for a patient with a proximal humeral fracture on aspirin (acetylsalicylic acid) and clopidogrel (antiplatelet medication)?

Operative Plan for Proximal Humeral Fracture in Patient on Aspirin and Clopidogrel

Primary Recommendation

Continue aspirin throughout the perioperative period and discontinue clopidogrel 5 days before surgery, resuming it as soon as possible postoperatively (ideally within 24-48 hours). 1, 2

Preoperative Antiplatelet Management

Aspirin Management

• Maintain aspirin without interruption through the entire perioperative period 1, 2
• Proximal humeral fracture surgery represents intermediate bleeding risk where aspirin continuation is safe and reduces cardiovascular complications 2
• The thrombotic risk of aspirin discontinuation exceeds the bleeding risk in orthopedic fracture surgery 2, 3

Clopidogrel Management

• Stop clopidogrel exactly 5 days before the scheduled surgery to allow adequate platelet recovery 1
• This 5-day window balances platelet half-life considerations with bleeding risk while minimizing thrombotic complications 1
• Never discontinue both aspirin and clopidogrel simultaneously, as this dramatically increases cardiovascular event risk 2, 4

Critical Cardiac Risk Assessment Required

Before proceeding, you must determine if this patient has coronary stents:

If Drug-Eluting Stent (DES) placed <6-12 months ago:

• Ideally postpone surgery until after this period if the fracture allows conservative management 1, 4
• If surgery cannot be delayed: maintain aspirin, stop clopidogrel 5 days preoperatively, resume immediately postoperatively with 300mg loading dose 1, 4
• Convene multidisciplinary meeting with cardiology, orthopedics, and anesthesia to document risk-benefit analysis 1, 4

If Bare-Metal Stent (BMS) placed <4-6 weeks ago:

• Surgery should ideally be postponed 4
• If urgent, consider maintaining both agents given extreme stent thrombosis risk 4

If no stents or stents placed beyond critical timeframes:

• Proceed with standard plan (continue aspirin, stop clopidogrel 5 days prior) 1, 2

Intraoperative Considerations

Anesthetic Approach

• Regional anesthesia (interscalene block) is contraindicated while on clopidogrel 1
• Deep nerve blocks require clopidogrel discontinuation 5 days prior 1
• General anesthesia is the preferred approach if surgery cannot be delayed 5 days 1
• Superficial blocks may be performed with ultrasound guidance by experienced operators even on aspirin alone 1

Hemostatic Measures

• Consider tranexamic acid (TXA) administration to reduce blood loss, as it has proven efficacy in proximal humeral fracture surgery 5
• TXA reduces total blood loss by approximately 90mL and decreases hemoglobin drop by 1.1 g/dL without increasing thrombotic complications 5
• Have platelet concentrates available but rarely needed 6
• Antifibrinolytic therapy is first-line for bleeding management 6

Surgical Technique Modifications

• Use meticulous hemostasis throughout the procedure 5
• Place surgical drain and monitor 24-hour output 5
• Consider minimally invasive approaches when feasible to reduce bleeding 5

Postoperative Management

Antiplatelet Resumption

• Resume clopidogrel within 24-48 hours postoperatively once surgical hemostasis is secure 1, 6
• Consider 300mg loading dose of clopidogrel on resumption 1
• Continue aspirin without interruption 1, 2

Thromboprophylaxis

• Aspirin provides adequate thromboprophylaxis for upper extremity fracture surgery 7
• Add pneumatic compression devices and early mobilization 7
• Do NOT use LMWH as bridging therapy or substitute for antiplatelet agents, as it does not prevent stent thrombosis and increases bleeding risk 1, 2, 4

Monitoring

• Monitor hemoglobin on postoperative day 1 5
• Assess drain output at 24 hours 5
• Watch for signs of bleeding or cardiovascular events 6

Critical Pitfalls to Avoid

• Never substitute heparin or LMWH for antiplatelet therapy in patients with coronary stents—this does not protect against stent thrombosis 2, 4
• Never stop both aspirin and clopidogrel simultaneously in patients with recent stent placement 2, 4
• Never perform neuraxial anesthesia while patient is on clopidogrel (must wait 5 days after discontinuation) 1
• Never delay clopidogrel resumption unnecessarily postoperatively, as each day increases stent thrombosis risk 1