The Case Challenge series includes difficult-to-diagnose conditions, some of which are not frequently encountered by most clinicians but are nonetheless important to accurately recognize. Test your diagnostic and treatment skills using the following patient scenario and corresponding questions. If you have a case that you would like to suggest for a future Case Challenge, please contact us.
A 59-year-old woman presents to the emergency department after a low-impact mechanical fall, which resulted in a right femur shaft fracture. Her past medical history includes hypertension, diabetes, heart failure with reduced ejection fraction, coronary artery disease treated by percutaneous coronary intervention (PCI), and obstructive sleep apnea treated with continuous positive airway pressure.
The patient undergoes open reduction and internal fixation with intramedullary rod placement. She has an uneventful perioperative hospital course, and heparin is started for deep venous thromboembolism prophylaxis. In the recovery room, she becomes hypoxic and receives empiric antibiotic therapy with piperacillin-tazobactam to cover aspiration pneumonia. On postoperative day 2, the antibiotic therapy is discontinued after the workup reveals aspiration pneumonitis, which improves with supportive measures.
On postoperative day 3, the patient has chest pain and dyspnea of sudden onset. CT angiography of the chest shows a segmental pulmonary embolism with no signs of right ventricular strain on imaging (Figure 1). Her heparin dose is adjusted for treatment of thromboembolism, and her symptoms gradually improve over the next 2 days. During the course of her hospital stay, a gradual decline in her platelet count is noted.
She has no personal history of cancer. She is up-to-date on her age-appropriate cancer screening, and the results of a colonoscopy and a mammogram performed within the past 2 years were normal. She has no history of alcohol or substance use.
Three years ago, the patient had a motor vehicle accident that resulted in multiple rib fractures and a humeral fracture with acute blood loss anemia, which necessitated a stay in the intensive care unit. She required a massive transfusion protocol during her hospital stay with multiple blood products, including packed red blood cells, platelets, and fresh frozen plasma.
Treatment of her heart failure has been optimized with goal-directed medical therapy. Her ejection fraction has risen from 25% after her PCI 2 years ago to 60% on the echocardiogram performed 3 months before her current hospitalization. She takes metformin for her diabetes, and her most recent A1c level was 7% about 2 months ago. She has been compliant with her periodic primary care and cardiology follow-up visits. She reports no active tobacco consumption. She drinks alcohol occasionally and has no history of illicit drug use.
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Cite this: Hematologic Complications After Femoral Fracture Surgery - Medscape - Nov 15, 2023.