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International Orthopaedics

, Volume 41, Issue 9, pp 1729–1734 | Cite as

Fat emboli syndrome and the orthopaedic trauma surgeon: lessons learned and clinical recommendations

  • Robin Hall Dunn
  • Trevor Jackson
  • Clay Cothren Burlew
  • Fredric M. Pieracci
  • Charles Fox
  • Mitchell Cohen
  • Eric M. Campion
  • Ryan Lawless
  • Cyril MauffreyEmail author
Original Paper

Abstract

Purpose

Fat emboli syndrome is a rare but well-described complication of long-bone fractures classically characterised by a triad of respiratory failure, mental status changes and petechial rash. In this paper, we present the case of a patient who sustained bilateral femoral fractures and subsequently developed FES. Our aim was to review and summarise the current literature regarding the pathophysiology and management of fat emboli syndrome (FES) and propose an algorithm for treating patients with bilateral femoral fractures to reduce the risk of FES.

Methods

A literature analysis was performed to determine implications in the clinical setting.

Results

Currently, there exists little high-quality evidence to guide the orthopaedic surgeon in identifying patients at highest risk of FES or in preventing FES in patients with multiple long-bone fractures. However, the literature does suggest that the risk is directly related to the volume of marrow displaced and inversely related to both the time to fracture stabilisation and the respiratory reserve of the patient. Based on these correlations, we propose an algorithm for treating patients with bilateral femoral fractures, taking into consideration haemodynamic and pulmonary stability.

Conclusions

Our algorithm for managing bilateral femoral fractures prioritises early stabilisation with external fixation, staged intramedullary nailing and conversion to plate fixation if FES develops. This protocol is meant to be the basis of future investigations of optimal treatment strategies.

Keywords

Fat emboli syndrome Bilateral femur fractures Damage control orthopaedics Complication Femur shaft fracture 

Notes

Compliance with ethical standards

Conflict of interest

The authors declare that they have no conflict of interest.

Funding

There is no funding source.

Ethical approval

This article does not contain any studies with human participants or animals performed by any of the authors.

References

  1. 1.
    Akoh CC, Schick C, Otero J, Karam M (2014) Fat embolism syndrome after femur fracture fixation: a case report. Iowa Orthop J 34:55–62PubMedPubMedCentralGoogle Scholar
  2. 2.
    Talbot M, Schemitsch EH (2006) Fat embolism syndrome: history, definition, epidemiology. Injury 37(Suppl 4):S3–S7CrossRefPubMedGoogle Scholar
  3. 3.
    Bone LB, Johnson KD, Weigelt J, Scheinberg R (1989) Early versus delayed stabilization of femoral fractures: a prospective randomized study. Clin Orthop Relat Res 71(3):336–340Google Scholar
  4. 4.
    Gossling HR, Donohue TA (1979) The fat embolism syndrome. JAMA 241(25):2740–2742CrossRefPubMedGoogle Scholar
  5. 5.
    Sevitt S (1977) The significance and pathology of fat embolism. Ann Clin Res 9(3):173–180PubMedGoogle Scholar
  6. 6.
    Gossling HR, Pellegrini VD (1982) Fat embolism syndrome: a review of the pathophysiology and physiological basis of treatment. Clin Orthop Relat Res. (165): 68-82Google Scholar
  7. 7.
    Hofmann S, Huemer G, Salzer M (1998) Pathophysiology and management of the fat embolism syndrome. Anaesthesia 53(Suppl 2):35–37PubMedGoogle Scholar
  8. 8.
    Fabian TC, Hoots AV, Stanford DS, Patterson CR, Mangiante EC (1990) Fat embolism syndrome: prospective evaluation in 92 fracture patients. Crit Care Med 18(1):42–46CrossRefPubMedGoogle Scholar
  9. 10.
    Byrick RJ, Korley RE, Mckee MD, Schemitsch EH (2001) Prolonged coma after unreamed, locked nailing of femoral shaft fracture. Anesthesiology 94(1):163–165CrossRefPubMedGoogle Scholar
  10. 11.
    Gurd AR, Wilson RI (1972) Fat-embolism syndrome. Lancet 2(7770):231–232CrossRefPubMedGoogle Scholar
  11. 12.
    Schonfeld SA, Ploysongsang Y, Dilisio R et al (1983) Fat embolism prophylaxis with corticosteroids. A prospective study in high-risk patients. Ann Intern Med 99(4):438–443CrossRefPubMedGoogle Scholar
  12. 13.
    Lindeque BG, Schoeman HS, Dommisse GF, Boeyens MC, Vlok AL (1987) Fat embolism and the fat embolism syndrome. A double-blind therapeutic study. J Bone Joint Surg Br 69(1):128–131PubMedGoogle Scholar
  13. 14.
    Christie J, Robinson CM, Pell AC, Mcbirnie J, Burnett R (1995) Transcardiac echocardiography during invasive intramedullary procedures. J Bone Joint Surg Br 77(3):450–455PubMedGoogle Scholar
  14. 15.
    Husebye EE, Lyberg T, Røise O (2006) Bone marrow fat in the circulation: clinical entities and pathophysiological mechanisms. Injury 37(Suppl 4):S8–18CrossRefPubMedGoogle Scholar
  15. 16.
    Charash WE, Fabian TC, Croce MA (1994) Delayed surgical fixation of femur fractures is a risk factor for pulmonary failure independent of thoracic trauma. J Trauma 37(4):667–672CrossRefPubMedGoogle Scholar
  16. 17.
    Johnson KD, Cadambi A, Seibert GB (1985) Incidence of adult respiratory distress syndrome in patients with multiple musculoskeletal injuries: effect of early operative stabilization of fractures. J Trauma 25(5):375–384CrossRefPubMedGoogle Scholar
  17. 18.
    Mellor A, Soni N (2001) Fat embolism. Anaesthesia 56(2):145–154CrossRefPubMedGoogle Scholar
  18. 19.
    Tachakra SC, Potts D, Idowu A (1990) Early operative fracture management of patients with multiple injuries. Br J Surg 77(10):1194CrossRefPubMedGoogle Scholar
  19. 20.
    Aoki N, Soma K, Shindo M, Kurosawa T, Ohwada T (1998) Evaluation of potential fat emboli during placement of intramedullary nails after orthopedic fractures. Chest 113(1):178–181CrossRefPubMedGoogle Scholar
  20. 21.
    Volgas DA, Burch T, Stannard JP, Ellis T, Bilotta J, Alonso JE (2010) Fat embolus in femur fractures: a comparison of two reaming systems. Injury 41(Suppl 2):S90–S93CrossRefPubMedGoogle Scholar
  21. 22.
    Shah S, Desai P, Mounasamy V (2015) Retrograde nailing of femoral fractures: a retrospective study. Eur J Orthop Surg Traumatol 25(6):1093–1097. doi: 10.1007/s00590-015-1658-6 CrossRefPubMedGoogle Scholar
  22. 23.
    Giannoudis PV, Cohen A, Hinsche A, Stratford T, Matthews SJ, Smith RM (2000) Simultaneous bilateral femoral fractures: systemic complications in 14 cases. Int Orthop 24(5):264–267. doi: 10.1007/s002640000161 CrossRefPubMedPubMedCentralGoogle Scholar
  23. 24.
    White T, Petrisor BA, Bhandari M (2006) Prevention of fat embolism syndrome. Injury 37(Suppl 4):S59–S67CrossRefPubMedGoogle Scholar
  24. 25.
    Bonnevialle P, Cauhepe C, Alqoh F, Bellumore Y, Rongières M, Mansat M (2000) Risks and results after simultaneous intramedullary nailing in bilateral femoral fractures: a retrospective study of 40 cases (French). Rev Chir Orthop Reparatrice Appar Mot 86(6):598–607PubMedGoogle Scholar
  25. 26.
    Zalavras C, Velmahos GC, Chan L, Demetriades D, Patzakis MJ (2005) Risk factors for respiratory failure following femoral fractures: the role of multiple intramedullary nailing. Injury 36(6):751–757CrossRefPubMedGoogle Scholar
  26. 27.
    Kontakis GM, Tossounidis T, Weiss K, Pape HC, Giannoudis PV (2006) Fat embolism: special situations bilateral femoral fractures and pathologic femoral fractures. Injury 37(Suppl 4):S19–S24CrossRefPubMedGoogle Scholar
  27. 28.
    Cox G, Jones E, Mcgonagle D et al. (2011) Reamer-irrigator-aspirator indications and clinical results: a systematic review. Int Orthop, (7): p. 951-956.Google Scholar
  28. 29.
    Streubel PN, Desai P, Suk M (2010) Comparison of RIA and conventional reamed nailing for treatment of femur shaft fractures. Injury 41(Suppl 2):S51–S56CrossRefPubMedGoogle Scholar
  29. 30.
    Schemitsch EH, Jain R, Turchin DC et al (1997) Pulmonary effects of fixation of a fracture with a plate compared with intramedullary nailing. A canine model of fat embolism and fracture fixation. J Bone Joint Surg Am 79(7):984–996CrossRefPubMedGoogle Scholar
  30. 31.
    Bosse MJ, Mackenzie EJ, Riemer BL et al (1997) Adult respiratory distress syndrome, pneumonia, and mortality following thoracic injury and a femoral fracture treated either with intramedullary nailing with reaming or with a plate. A comparative study. J Bone Joint Surg Am 79(6):799–809CrossRefPubMedGoogle Scholar

Copyright information

© SICOT aisbl 2017

Authors and Affiliations

  1. 1.Department of OrthopedicsUniversity of Colorado School of MedicineAuroraUSA
  2. 2.Department of surgeryDenver Health Medical CenterDenverUSA
  3. 3.Department of Orthopaedic SurgeryDenver Health Medical CenterDenverUSA

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