Can Arm Fractures Lead to Pulmonary Embolism?
Yes, arm fractures can lead to pulmonary embolism, though the risk is substantially lower than with lower extremity fractures—but it is not negligible, particularly after surgical fixation of proximal humerus fractures.
Risk Stratification by Fracture Location
The risk of venous thromboembolism (VTE) varies significantly based on the specific location of the upper extremity fracture:
- Proximal humerus fractures carry the highest risk at approximately 3.0% for VTE and 5.1% for pulmonary embolism after operative treatment 1, 2.
- Clavicle fractures have an intermediate risk at approximately 2.0% 2.
- Distal radius/ulna fractures carry the lowest risk at 0.14-0.95% 2.
Lower limb fractures remain a strong risk factor (OR >10) for pulmonary embolism, while upper extremity fractures are not classified in this highest-risk category by major guidelines 3.
Mechanism and Clinical Context
Upper extremity fractures can cause pulmonary embolism through two primary mechanisms:
- Subclavian or axillary vein thrombosis that propagates to cause pulmonary embolism, particularly after proximal humerus surgery 4.
- Immobilization-related venous stasis, though bed rest >3 days is only a weak risk factor (OR <2) 3.
Fatal pulmonary embolism has been documented after proximal humeral fracture surgery, though death is uncommon 4, 1.
High-Risk Features Requiring Enhanced Vigilance
Certain patient characteristics substantially increase the risk beyond the fracture itself:
- Chronic steroid use (OR = 6.22) 2
- Totally disabled functional status (OR = 3.31) 2
- Inpatient status (OR = 4.09) 2
- Active malignancy or metastatic disease 5, 6
- Known thrombophilia or hypercoagulable state 5
- Recent myocardial infarction or heart failure hospitalization within 3 months 6, 7
Prophylaxis Recommendations
Mechanical prophylaxis should be used intraoperatively and during the immediate postoperative period for all shoulder arthroplasty patients, and this principle extends to proximal humerus fracture surgery 5.
Chemical prophylaxis beyond aspirin should be considered for patients with specific high-risk features including active malignancy, known thrombophilia, or recent thromboembolic events 5, 6.
For standard-risk patients undergoing proximal humerus surgery, the evidence supports mechanical prophylaxis as the baseline approach, with chemical prophylaxis reserved for those with additional risk factors 5.
Critical Clinical Pitfalls
- Do not assume upper extremity fractures carry negligible VTE risk—the 5.1% pulmonary embolism rate after operative proximal humerus fracture treatment is clinically significant 1.
- Early mobilization reduces risk of atelectasis, pneumonia, DVT, and pulmonary embolism when patients are hemodynamically stable 3.
- Immobility complications account for up to 51% of deaths in the first 30 days after stroke, demonstrating the importance of mobilization in any immobilized patient 3.
- VTE can occur even in children with routine fractures, though this is exceedingly rare 8.
Temporal Considerations
Pulmonary embolism risk is highest during the first 2 postoperative weeks but remains elevated for 2-3 months after major surgery 6. The median time to VTE after upper extremity fracture in documented cases ranges from 4-10 days postoperatively 4, 1.