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Achilles tendon rupture with lower-limb immobilisation — MSRA MCQ

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ModerateAnkle and FootAchilles tendon rupture with lower-limb immobilisationMSRA

A 72-year-old woman is seen in an urgent treatment centre after sustaining a complete Achilles tendon rupture. She has been placed in an equinus below-knee cast and is toe-touch weight-bearing pending fracture-clinic review. She has a BMI of 34 kg/m², chronic kidney disease G4 (creatinine clearance 27 mL/min), and a previous postoperative deep-vein thrombosis 12 years ago. She has no active bleeding, thrombocytopenia, recent stroke, peptic ulceration or concurrent anticoagulant treatment. A VTE and bleeding-risk assessment identifies that her VTE risk outweighs her bleeding risk. What is the most appropriate additional management today?

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

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Correct answer: D — Start renal-adjusted prophylactic low-molecular-weight heparin and review the need for prophylaxis if immobilisation continues beyond 42 days

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

This patient has lower-limb immobilisation: the equinus cast and toe-touch weight-bearing prevent normal use and weight-bearing of the affected limb. Her risk is further increased by older age, obesity and previous VTE. As the documented VTE assessment judges this risk to outweigh bleeding risk, NICE recommends considering pharmacological prophylaxis with LMWH or fondaparinux. LMWH is appropriate here, but her creatinine clearance of 27 mL/min requires renal dose adjustment; enoxaparin exposure increases in severe renal impairment. A is attractive because the injury is treated conservatively, but NICE recommendations apply to immobilisation irrespective of whether operative treatment is planned. C is not the recommended standard option for lower-limb immobilisation; apixaban prophylaxis is licensed for elective hip or knee replacement surgery. D does not replace indicated pharmacological prophylaxis in this high-risk situation and is impractical over a casted limb. E misses the need to assess and act at discharge from urgent care rather than postponing risk management. NICE advises reconsidering prophylaxis if immobilisation extends beyond 42 days.

Reference: Venous thromboembolism in over 16s: reducing the risk of hospital-acquired deep vein thrombosis or pulmonary embolism (NG89) — Recommendations (2018, amended 2021) — https://www.nice.org.uk/guidance/ng89/chapter/Recommendations NG89 draft guideline evidence — Lower limb immobilisation (2017) — https://www.nice.org.uk/guidance/ng89/documents/draft-guideline-4 Clexane Pre-filled Syringes — Summary of Product Characteristics (2026) — https://www.medicines.org.uk/emc/product/4499/smpc