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Suspected postoperative deep vein thrombosis after total hip replacement — MSRA MCQ

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ModerateHip and GroinSuspected postoperative deep vein thrombosis after total hip replacementMSRA

A 72-year-old woman presents to her GP 16 days after an uncomplicated elective right total hip replacement performed under spinal anaesthesia. Since yesterday, she has developed increasing aching pain in the right groin and calf with swelling of the whole right leg. She is mobilising with crutches. There is no wound discharge, erythema or fever. She has no chest pain, breathlessness or haemoptysis. Examination shows the right leg is diffusely swollen from thigh to ankle, with pitting oedema confined to that leg and tenderness along the deep calf veins. The calf circumference is 4 cm greater than on the left. Her observations are normal. A proximal leg vein ultrasound scan cannot be performed until tomorrow morning, in approximately 18 hours. What is the most appropriate immediate management?

Educational content. Not a substitute for clinical judgement or local policy.

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Correct answer: B — Start interim therapeutic anticoagulation, obtain a D-dimer test, and arrange a proximal leg vein ultrasound scan within 24 hours

Explanation lettering: E = shown as A · A = shown as C · C = shown as D · D = shown as E

This woman has a likely DVT Wells score: major surgery within 12 weeks (+1), localised tenderness along the deep venous system (+1), entire leg swollen (+1), calf swelling at least 3 cm greater than the other side (+1), and unilateral pitting oedema (+1). Postoperative oedema is not at least as likely as DVT given the extent of swelling, calf tenderness and acute deterioration. Her score is therefore 5. For a likely DVT, NICE recommends a proximal leg vein ultrasound scan with a result available within 4 hours where possible. If this cannot be achieved, give interim therapeutic anticoagulation, obtain a D-dimer test, and ensure proximal leg vein ultrasound is available within 24 hours. Baseline blood tests should be taken but treatment should not await their results. A is inadequate because imaging is delayed beyond 4 hours without interim anticoagulation. C incorrectly applies the D-dimer-led pathway used for an unlikely Wells score. D would be appropriate if there were suspected pulmonary embolism, haemodynamic compromise or another acute postoperative complication, none of which is present. E risks delaying diagnosis and treatment of a potentially proximal postoperative DVT.

Reference: NICE NG158: Venous thromboembolic diseases: diagnosis, management and thrombophilia testing — Recommendations (Recommendations amended 2020; guideline update information checked February 2026) — https://www.nice.org.uk/guidance/ng158/chapter/Recommendations NICE NG158 visual summary: Suspected DVT diagnosis and initial management (2 August 2023) — https://www.nice.org.uk/guidance/ng158/resources/visual-summary-pdf-11193380893 NICE NG158: Update information (February 2026) — https://www.nice.org.uk/guidance/ng158/chapter/Update-information