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Difficulty: MediumPreoperative and Postoperative Care

Six days following an open reduction and internal fixation of a right proximal femur fracture, a 69-year-old female patient reports new-onset right leg discomfort. She has been participating in daily physical therapy but states her right leg feels unusually heavy and painful today. Her temperature is 38.3°C (100.9°F), blood pressure is 128/82 mmHg, pulse is 94/min, and respiratory rate is 16/min. Pulse oximetry shows 98% on room air. Examination reveals that the surgical incision over the lateral hip is well-approximated, dry, and without erythema or drainage. However, the right calf and lower thigh are visibly edematous, warm, and tender to deep palpation. Cardiopulmonary examination is unremarkable, and she denies dysuria, cough, or shortness of breath. Which of the following is the most appropriate next step in the management of this patient?

  1. A
    Administer intravenous piperacillin-tazobactam and vancomycin
  2. Duplex ultrasonography of the right lower extremityAnswer
  3. C
    Computed tomography angiography of the chest
  4. D
    Obtain urinalysis and urine culture
  5. E
    Bedside exploration of the surgical wound

Answer

The most appropriate next step is to perform duplex ultrasonography of the right lower extremity.
The correct answer is to perform duplex ultrasonography of the right lower extremity. This patient's presentation of new-onset unilateral leg edema, warmth, and tenderness on postoperative day 6 is highly suspicious for a deep vein thrombosis (DVT). Major orthopedic procedures, particularly of the hip and femur, carry a very high risk for venous thromboembolism due to endothelial injury, venous stasis, and a hypercoagulable state (Virchow's triad). A low-grade fever can simply be a systemic inflammatory response to the venous clot and represents the 'Walking' component of the classic postoperative fever etiologies (the '5 Ws'). The most appropriate and definitive initial step to confirm this diagnosis is a lower extremity compression duplex ultrasound, which evaluates for the presence of a non-compressible vein.

Step-by-Step Solution

1
Analyze the patient's postoperative timeline and vital signs.
The patient is on postoperative day 6 with a new-onset fever (38.3°C).
Timing helps narrow down the differential diagnosis for postoperative fever using the '5 Ws' (Wind, Water, Walking, Wound, Wonder drugs).
2
Evaluate the physical examination findings.
The surgical incision is benign, ruling out an obvious superficial wound infection. The presence of unilateral right calf and thigh edema, warmth, and tenderness strongly points to a local deep venous pathology.
Physical exam findings must guide the targeted diagnostic approach. The combination of major orthopedic surgery and unilateral leg swelling is the classic presentation for deep vein thrombosis (the 'Walking' etiology).
3
Determine the optimal diagnostic study for the suspected condition.
Lower extremity duplex ultrasonography is selected to visualize venous flow and vein compressibility.
Ultrasound is the non-invasive gold standard for confirming the presence of a deep vein thrombosis prior to initiating systemic anticoagulation.

Key Concept

Patients who undergo major orthopedic surgery are at high risk for deep vein thrombosis (DVT), which typically presents between postoperative days 5 and 7 ('Walking') with unilateral limb swelling, tenderness, and sometimes a low-grade fever. The best initial test is a compression duplex ultrasound.
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Topics

Preoperative and Postoperative Care

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