Homans Sign: A Sign of What? COPYRIGHT © 2016, ALL RIGHTS RESERVED From the Publishers of

Terms of Use The Consult Guys ® slide sets are owned and copyrighted by the American College of Physicians (ACP). All text, graphics, trademarks, and other intellectual property incorporated into the slide sets remain the sole and exclusive property of ACP. The slide sets may be used only by the person who downloads or purchases them and only for the purpose of presenting them during not-for-profit educational activities. Users may incorporate the entire slide set or selected individual slides into their own teaching presentations but may not alter the content of the slides in any way or remove the ACP copyright notice. Users may make print copies for use as hand-outs for the audience the user is personally addressing but may not otherwise reproduce or distribute the slides by any means or media, including but not limited to sending them as attachments, posting them on Internet or Intranet sites, publishing them in meeting proceedings, or making them available for sale or distribution in any unauthorized form, without the express written permission of the ACP. Unauthorized use of the Consult Guys ® slide sets constitutes copyright infringement. Copyright © 2016

Guys: I am in our ED and I need you gurus to settle a disagreement. I am outside the room of a 63-year-old man who presented with a swollen right calf. Eight weeks ago he underwent inguinal hernia repair. There were no complications, he was treated with 1ntermittent pneumatic compression during surgery. He was ambulatory post surgery. Nine days ago he sustained soft tissue trauma to the right leg. Seven days ago he noted intermittent pain in the right calf. He was able to provoke the pain by compressing the calf. He came to the ED several hours ago. He has been healthy. So here is the problem. The ED physician says that with the negative D Dimer that this is not DVT and the patient can go home without further evaluation. I think that with the reproduction of posterior knee pain with dorsiflexion of the right foot that he has a positive “Homans Sign” and that the likelihood of DVT is high. I need you guys to weigh in. Guys: I am in our ED and I need you gurus to settle a disagreement. I am outside the room of a 63-year-old man who presented with a swollen right calf. Eight weeks ago he underwent inguinal hernia repair. There were no complications, he was treated with 1ntermittent pneumatic compression during surgery. He was ambulatory post surgery. Nine days ago he sustained soft tissue trauma to the right leg. Seven days ago he noted intermittent pain in the right calf. He was able to provoke the pain by compressing the calf. He came to the ED several hours ago. He has been healthy. So here is the problem. The ED physician says that with the negative D Dimer that this is not DVT and the patient can go home without further evaluation. I think that with the reproduction of posterior knee pain with dorsiflexion of the right foot that he has a positive “Homans Sign” and that the likelihood of DVT is high. I need you guys to weigh in.

Copyright © 2016 Exam Swollen calf eight weeks after hernia repair 9 days after leg trauma Afebrile BP 120/70 Right calf dimension: 34cm Left calf dimension: 32cm No erythema or edema No trauma Dorsiflexion of the right foot results in reproduction of posterior knee pain There is an area of bruising along the right medial malleolus Hgb / Hct 14 grams / 42 D Dimer: normal value No history of cancer No history DVT

Copyright © 2016

Hernia Surgery 8 Weeks Ago  DVT risk?  Was he given the correct DVT prophylaxis?

Copyright © 2016 DVT or No DVT?

Copyright © 2016 Was the DVT prophylaxis appropriate? Caprini score = 2: Low risk for DVT = Intermittent Pneumatic Compression Ann Intern Med. 2015;162(9):ITC1. doi: /AITC

*Homans J. Exploration and Division of the Femoral and Iliac Veins in the Treatment of Thrombophlebitis of the Leg. N Engl J Med 1941; 224:

Copyright © 2016 Modified Wells Score < 1 DVT Unlikely Ann Intern Med. 2015;162(9):ITC1. doi: /AITC

Copyright © 2016 Primary Care Rule = 1 DVT Unlikely Ann Intern Med. 2015;162(9):ITC1. doi: /AITC

From: Deep Venous Thrombosis Ann Intern Med. 2015;162(9):ITC1. doi: /AITC DVT treatment algorithm. DVT = deep venous thrombosis. Figure Legend: Copyright © 2016

Pearls from the Guys  Calf pain 8 weeks post hernia repair and had appropriate DVT prophylaxis relating to the surgery  9 days post leg trauma  Physical exam signs of DVT are unreliable  Forget “Homans Sign”  Determine whether DVT “Likely” or “Unlikely”  Wells Score  Primary Care rule  When indicated, use D-Dimer  No need for imaging if DVT is “Unlikely” and the D-Dimer is negative  Consider other causes of calf pain

Copyright © 2016 COPYRIGHT © 2016, ALL RIGHTS RESERVED Produced by and