Madtown Sono

Middle-aged male with leg pain

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By Dana Resop, MD
Edited by Hani I. Kuttab, MD

Clinical Case

A middle-aged male truck driver came to your community emergency department complaining of right calf pain and swelling. Vital signs include a heart rate of 65 and blood pressure of 120/68. The patient denied any relevant medical history or family history and denied taking any medications. He does endorse smoking cigarettes and works as a long-range truck driver. Physical exam was significant for a moderately swollen right calf and tenderness to palpation in the mid-thigh. Some slight erythema with poorly demarcated borders at the medial thigh was also noted and distal pulses were otherwise intact.

He is driving across the country and stopped because his leg bothers him while he drives; he states he has to be back on the road at 5:30 AM, and cannot wait for you to call in an overnight ultrasound tech. You pull out your trusty ultrasound and obtain the following images (Figure 1).

Bedside ultrasound of the common femoral and femoral veins
Figure 1. Bedside ultrasound of the common femoral and femoral veins

Diagnosis

Deep Venous Thrombosis (DVT). You diagnose a clot at the femoral vein, start patient on blood thinners, and recommend cessation of smoking given this new diagnosis. He is discharged from the emergency department and referred to his primary care doctor for follow-up.

Frequencies of clot locations by Adhikari et al.
Figure 2. Frequencies of clot locations by Adhikari et al. (2)

A study by Adhikari et. al., reviewed emergency department ultrasounds and identified the various locations of DVTs. It found that, although most clots are caught on compression of the proximal femoral vein and popliteal vein (i.e. 2-point compression), continuing compression into femoral vein and checking the deep femoral vein will catch ~6% of patients with DVT. In other words, if you do not check the veins in between the proximal femoral and popliteal veins, you will miss 1 in 20 patients with a DVT. This study suggests that the evaluation of femoral and deep femoral vein compression should be included in the bedside DVT evaluation.

Teaching Point

When evaluating for DVTs, be sure to look distal to the common femoral vein!

References

  1. Kim SH, Patel N, Thapar K, Pandurangadu AV, Bahl A Isolated proximal greater saphenous vein thrombosis and the risk of propagation to deep vein thrombosis and pulmonary embolism..Vasc Health Risk Manag. 2018 Jun 12;14:129-135.
  2. Adhikari, S . Zeger, W. Thom, C. Fields, M. Isolated Deep Venous Thrombosis: Implications for 2-Point Compression Ultrasonography of the Lower Extremity. Ann Emerg Med. 2014;1.