In daily practice, venous thromboembolism (VTE) in pediatric orthopedics remains an uncomfortable topic: rare, but not negligible. Precisely because events are few, it's easy to swing between two opposite extremes: treating it as an almost theoretical complication, or excessively applying protocols designed for adults. Recent literature, however, is moving in a more useful direction: not so much seeking a single rule, but better understanding in which patients the risk truly changes. [1][2][4]
The systematic review by Boulet and colleagues is a good starting point, and in my opinion, it should be read precisely in this way. The authors included 70 studies (845,010 patients) and confirm that VTE in pediatric orthopedics is, overall, a rare event: a global median incidence of 0.16%. The data that truly shifts attention is another: in musculoskeletal infections, the median incidence rises to 3.5%, a completely different order of magnitude compared to standard elective surgery. [1]
This result is consistent with what many see in the ward: a healthy child undergoing elective surgery is not the same patient as an adolescent with major trauma or a child hospitalized for osteoarticular infection, systemic inflammation, and immobilization. And this is precisely where Boulet's review is useful: it doesn't provide a "recipe," but it puts solid numbers to a widespread clinical perception. [1]
That said, to properly reason about puberty, skeletal maturity, and patient weight, Boulet's review alone is not enough. It needs to be supplemented.
A second systematic review, published in JBJS Open Access (Mulpuri et al.), arrives at a very similar message regarding overall risk (approximately 16.6 events per 10,000 pediatric orthopedic patients), but adds a central detail: among the most frequently analyzed risk factors are age, sex, obesity/body mass index, type of intervention, and central venous catheter. Furthermore, in traumatic cases, the risk is higher compared to elective settings. [2]
The interesting point here is that age is not just a demographic variable: in practice, it is often a surrogate for puberty and biological maturity. And indeed, the pediatric ICM-VTE recommendations (international consensus) explicitly state this: in pediatric literature, the concept of "skeletal maturity" is often approximated by chronological age, with terms like adolescence or puberty used interchangeably. In that document, the message is clear: below a certain threshold (prepubertal), it makes no sense to talk about routine pharmacological prophylaxis; above, especially from 13 years old and up and in the presence of other factors, the evaluation changes. [4]
This is an important step also from a terminological point of view, because it avoids misunderstandings. Today, the literature on VTE in pediatric orthopedics does not give us refined criteria based on bone age, Risser, Sanders, or other indicators of skeletal maturity. It mainly talks about chronological age and adolescence. So, if we want to be rigorous, we must say that skeletal maturity enters clinical reasoning, but in large studies, it is almost always indirectly represented by age, not specifically measured. [2][4]
Regarding the "specific weight" of the patient (in a clinical sense: obesity, comorbidity burden, case severity), the discussion is equally relevant. The work by Mets et al. on over 81,000 pediatric orthopedic surgeries shows a postoperative incidence of 0.07%, but clearly identifies some factors associated with VTE: age 16–18 years, higher ASA class, preoperative transfusion, arthrotomy, and femur fracture. This data, net of database limitations, brings us back to a very concrete principle: risk does not depend on a single label ("child" vs "adolescent"), but on the overall weight of the case. [3]
Obesity deserves a separate chapter. It does not always emerge as an independent factor in all analyses, but it regularly appears among the factors considered, along with age, type of surgery, and central venous catheter, and is now part of risk stratification in the most updated summaries. In practice, it is not an "on/off" switch, but an element that increases the level of attention, especially if combined with other factors (trauma, immobilization, infection, central venous access, major surgery). [2][4]
There is also a point that has become very difficult to ignore in recent works: the risk clearly increases in traumatized adolescents. Even more recent studies on surgically treated lower limb fractures show a clear difference between children and adolescents, with higher incidences in femoral and pelvic/hip fractures. [5] This is not an absolute novelty, but it reinforces the idea that age/puberty, injury site, and trauma intensity must enter the same clinical reasoning.
If I try to summarize in practical terms, recent literature is pushing us towards a less ideological and more mature (in a methodological sense) position:
no universal pharmacological prophylaxis, but also no systematic underestimation. The real leap in quality is to clearly distinguish risk profiles.
In other words:
- the young, healthy child, undergoing short elective surgery, mobilized early, remains in a very low-risk category;
- the adolescent (especially post-pubertal), with major trauma, femur/pelvic fracture, musculoskeletal infection, obesity, or other associated factors, is another clinical category. [1][2][3][4][5]
This is where the literature is most convincing. It doesn't ask us to treat everyone the same way; it asks us to stop considering pediatric VTE as a single block.
Disclaimer
This content is for informational purposes only and does not replace individual clinical evaluation.
References
[1] Boulet M, Langlais T, Pelet S, Belzile É, Forsythe C. Incidence of venous thromboembolism in pediatric orthopedics: A systematic review. Orthop Traumatol Surg Res. 2025;111(3):103830. doi:10.1016/j.otsr.2024.103830. PMID: 38336248.
PubMed: https://pubmed.ncbi.nlm.nih.gov/38336248/
DOI: https://doi.org/10.1016/j.otsr.2024.103830
[2] Mulpuri N, Sanborn RM, Pradhan P, Miller PE, Canizares MF, Shore BJ. Pediatric Orthopaedic Venous Thromboembolism: A Systematic Review Investigating Incidence, Risk Factors, and Outcome. JBJS Open Access. 2024;9(1):e23.00107. doi:10.2106/JBJS.OA.23.00107. PMID: 38188190.
PubMed: https://pubmed.ncbi.nlm.nih.gov/38188190/
[3] Mets EJ, Pathak N, Galivanche AR, McLynn RP, Frumberg DB, Grauer JN. Risk Factors for Venous Thromboembolism in Children Undergoing Orthopedic Surgery. Orthopedics. 2022;45(1):31-37. doi:10.3928/01477447-20211124-06. PMID: 34846239.
PubMed: https://pubmed.ncbi.nlm.nih.gov/34846239/
DOI: https://doi.org/10.3928/01477447-20211124-06
[4] Recommendations from the ICM-VTE: Pediatric. The Journal of Bone and Joint Surgery. 2022. Consensus statements on pediatric orthopaedic VTE risk and prophylaxis (including age/puberty thresholds and the use of chronological age as proxy for skeletal maturity in much of the literature).
Journal page: https://journals.lww.com/jbjsjournal/fulltext/2022/03161/recommendations_from_the_icm_vte__pediatric.7.aspx
[5] Risk of venous thromboembolism in pediatric and adolescent patients undergoing surgical treatment of lower-extremity fractures. The Journal of Bone and Joint Surgery. 2025. Large matched analysis showing higher VTE risk in adolescents vs children, especially in femoral and pelvic/hip fractures.
Journal page: https://journals.lww.com/jbjsjournal/fulltext/2025/06040/risk_of_venous_thromboembolism_in_pediatric.1.aspx
