A 21-year-old female college student presented to the emergency department (ED) with severe pain in her left hip, thigh, and calf. The pain started suddenly when she was playing basketball a few hours earlier. She twisted her torso to shoot the ball and heard a “pop” in her left hip with immediate onset of pain, and she subsequently fell to her knees. She was initially able to ambulate but had worsening pain and rapid progression of swelling and mottling in the left leg from her hip to her ankle. She denied any pain or swelling in that extremity prior to the injury during the basketball game. With the exception of oral contraceptive use, she had no significant medical or family history.\nOn examination her left extremity was mottled, dusky, and cool to the touch from the hip to the toes and she had decreased dorsalis pedis and posterior tibial pulses when compared with the right extremity. The leg was markedly tender to palpation and sensation to light touch was diminished. Passive range of motion of the hip, knee, and ankle elicited severe pain.\nPOCUS was performed at the bedside to evaluate for arterial blood flow and deep venous thrombosis. This demonstrated normal color flow in the femoral and popliteal arteries (), but echogenic material was noted within the left common femoral vein extending distally to the popliteal vein and the veins were non-compressible (). Vascular surgery was immediately consulted, and while awaiting their arrival to the ED the patient was sent for an emergent computed tomography (CT) angiogram, which confirmed arterial patency and extensive deep venous thrombosis in the left popliteal, femoral, and iliac veins (). A heparin bolus was given and the patient was then taken to interventional radiology where she underwent partial thrombectomy, catheter-directed tissue plasminogen activator (tPA) treatment, and placement of an inferior vena cava (IVC) filter. By the next morning her leg was noted to be well-perfused, non-tender, and without swelling, and her pain had resolved. A workup for hypercoagulable states revealed heterozygosity for the Factor V Leiden mutation. She was discharged one week later on warfarin after bridging from enoxaparin.
A 74-year-old man presented to the emergency department after a motorcycle accident. He had a deformity in the right leg. His comorbidities were chronic obstructive pulmonary disease, ischemic cardiomyopathy due to myocardial infarction, atrial fibrillation, hypertension, and dyslipidemia. His medications included aspirin and clopidogrel. Following investigations in this admission, a brain computed tomography (CT) revealed that he had acute traumatic subdural hematoma that was managed with nonoperative treatment. His right leg was broken, which was diagnosed as a closed fracture of the tibia and fibula, and was managed conservatively. He had fractures at the left iliac crest and the left superior pubic rami. The neurovascular conditions were normal. During admission, he had acute dyspnea with desaturation but no chest pain at ten days after admission. On examination, his blood pressure was 102/78 mmHg, pulse rate was 100/min, respiratory rate was 24/min, and blood oxygen saturation (SpO2) was 90% in room air, which was not corrected with oxygen supplement. He had crepitation at his left lower lung but no wheezing. CT angiography of the chest was performed and showed acute PEs at the right superior and inferior trunk. He was found to have acute respiratory failure and hypotension after the chest CT angiography was finished. He was scheduled for an emergency operation for surgical pulmonary embolectomy.\nOn the next day at the surgical intensive care unit (ICU), he developed progressive left leg edema with cyanosis. He had no fever and he could still move his leg, but his pain could not be evaluated since he was delirious. On examination, his left lower limb exhibited discoloration at his left foot without any ulcer or bleb, moist skin, or pitting edema, and the left dorsalis pedis and posterior tibial pulse could be palpated (1+) but were diminished (). The motor functions remained intact. Doppler ultrasonography was performed and revealed an uncompressible vein along the midsuperior femoral vein to the popliteal vein. His laboratory investigation showed that the leukocytosis and creatinine level rose from 1.04 mg% to 1.62 mg% and creatinine phosphokinase (CPK) was 322 U/L. He was diagnosed with PCD at the left femoral vein. The intervention radiologist attempted a catheter-directed thrombectomy, but it failed because the guider could not pass through the intraluminal clot. The patient was scheduled for emergency operation again for surgical thrombectomy with fasciotomy of the left leg (). The operative finding was a thrombus in the femoral vein that was 10 cm in length (). The compartment pressures before performing the fasciotomy at the anterior, lateral, and superficial posterior compartments were 43 mmHg, 37 mmHg, and 47 mmHg, respectively. The deep posterior compartment pressure was not measured. After the operation, his pain was relieved and the left dorsalis pedis and posterior tibial pulse were normal. He continued on wound dressings and the fasciotomy was closed by split-thickness skin graft. He continued on oral anticoagulant drugs for six months and underwent elective ray amputation at five months after the PCD for a dry gangrenous left big toe.