Skip to main content

Fat embolism syndrome after nailing an isolated open tibial fracture in a stable patient: a case report

Abstract

Background

Fat embolism syndrome is a potentially fatal complication of long bone fractures. It is usually seen in the context of polytrauma or a femoral fracture. There are few reports of fat embolism syndrome occurring after isolated long bone fractures other than those of the femur.

Case presentation

We describe a case of fat embolism syndrome in a 33-year-old Caucasian man. He was being seen for an isolated Gustilo’s grade II open tibial fracture. He was deemed clinically stable, so we proceeded to treat the fracture with intramedullary reamed nailing. He developed fat embolism syndrome intraoperatively and was treated successfully.

Conclusion

This case caused us to question the use of injury severity scoring for isolated long bone fractures. It suggests that parameters that have been described in the literature other than that the patient is apparently clinically stable should be used to establish the best time for nailing a long bone fracture, thereby improving patient safety.

Background

Fat embolism syndrome (FES) is a potentially fatal complication (mortality 10-36)[1, 2] of long bone fractures. Classically described as the triad of hypoxia, petechiae, and neurological impairment, it is characterized by bone marrow fat entering the systemic circulation and the individual’s inflammatory response to it. The response can result in dysfunction of several organs, most importantly the lungs, brain, and skin. Although fat embolization occurs in the majority of patients with long bone fractures or during orthopedic procedures, clinical signs and symptoms occur in only 1-10% of these patients[2, 3]. Most of the reported cases occurred in patients with multiple traumatic injuries that resulted in the systemic inflammatory response syndrome, which causes multi-organ damage via a reaction to free fatty acids[2].

There are few reports of FES occurring after isolated long bone fractures other than in patients with a femoral fracture[4]–[7]. There is no consensus as yet regarding the most appropriate method of nailing these fractures or on the timing of the fixation to minimize the incidence of FES[8].

Our aim was to report a case of FES in a seemingly otherwise healthy patient who sustained an isolated open fracture of the tibia. There were no factors present that would predispose the patient to FES. Hence, the fracture was treated with reamed intramedullary nailing.

Case presentation

A 33-year-old healthy Caucasian male skier was transferred to our institution 48 hours after a ski accident. His left leg had been temporarily fixed with a plaster cast. The wound had been debrided, irrigated, and closed at a local ski resort hospital. A Gustilo grade II open left tibial fracture (42-A2.2 according to the Orthopaedic Trauma Association)[9, 10] was diagnosed (Figure 1). Reevaluation of the patient showed a Glasgow Coma Scale of 15, an Injury Severity Score (ISS)[11] of 9, a New Injury Severity Score (NISS)[12] of 9, and unremarkable chest radiography (Figure 2). No other sites of injury were identified.

Figure 1
figure 1

Radiograph of the left tibia at presentation in the emergency room.

Figure 2
figure 2

Anteroposterior and lateral radiographs of the left tibia after nailing.

Standard reamed antegrade tibial nailing was performed 6 hours later (Figure 3) with fluted, flexible, intramedullary reamers to insert a 12-mm T2 nail (Stryker/Howmedica, Rutherford, NJ, USA) with proximal and distal locking screws. Just after introduction of the nail, the overall state of the patient started to deteriorate, with decreased oxygen saturation and a confusional state. When the surgical procedure had been completed, the patient was transferred to the intensive care unit (ICU), where he presented with dyspnea, hypoxemia (blood gas analysis revealed the PO2 to be < 60 mmHg), and fever (38.5°C). Twenty-four hours later, petechiae appeared on the lateral chest and abdomen and on the right axilla (Figure 4). Chest radiography and contrast-enhanced computed tomography (CT) showed diffuse bilateral pulmonary infiltrates (snow-storm appearance) (Figures 5 and6).

Figure 3
figure 3

Normal preoperative anteroposterior chest radiograph.

Figure 4
figure 4

Petechiae on the patient’s lateral chest and abdomen.

Figure 5
figure 5

Anteroposterior chest radiograph after nailing. Note the diffuse bilateral infiltrates.

Figure 6
figure 6

Contrast-enhanced computed tomography scan of the chest. Note the diffuse bilateral infiltrates in the lungs.

During his 5-day stay in the ICU, the patient did not require intubation, although supplemental oxygen was provided (initially, 4 liters/min via nasal cannulae) under continuous pulse oximetry monitoring and repeated blood gas analyses until complete resolution of his symptoms. After 1 week the patient was asymptomatic, and his chest radiograph was normal. Echocardiography performed before hospital discharge showed no evidence of cardiac involvement that could explain a paradoxical fat embolism[4]. Outpatient follow-up was performed until the fracture healed completely and uneventfully.

Discussion

Fat embolism is usually diagnosed on the basis of clinical findings[1]–[3]. According to the literature, Gurd’s criteria[1], consisting of major and minor clinical features, is the most commonly used diagnostic tool. Up to now, the diagnosis of FES has remained clinical[3] without a reference gold standard system. Our patient showed the pathognomonic triad of petechiae, hypoxia, and confusion. Radiological and CT findings confirmed the diagnosis.

Reamed intramedullary nailing continues to be the gold standard for stabilizing femoral and tibial shaft fractures. Reaming of the femoral or tibial canal allows insertion of a larger-diameter nail, optimizing the mechanical environment. Also, with the release of the products of reaming (endogenous growth factors and reaming debris), it provides an osteogenic stimulus. It is known, however, that reaming the medullary canal stimulates the immunoinflammatory system, leading to a “second hit” phenomenon. This is especially true in patients with a high ISS and associated chest injuries[13, 14].

In an attempt to reduce the incidence of fat embolism during reaming and nailing of long bone fractures, the reamer/irrigator/aspirator (RIA) system was developed (Synthes, Paoli, PA, USA). Experimental data suggest that the RIA device prevents fat embolism, although clinical evidence is lacking[15].

From a pathological point of view, fat emboli occur in nearly all patients after long bone fractures, although in most patients they are benign and without clinical consequences[2]. The reason for the development of FES in some individuals and not others remains unclear.

Based on the ISS, Pape et al.[16] categorized patients with femoral fractures as being stable, borderline, unstable, or in extremis. Because our patient was clinically categorized as stable (ISS of 9, thoracic Abbreviated Injury Score of 0, NISS of 9), we performed the nailing procedure. From an immunological point of view, our patient probably was not stable. He was likely borderline stable/unstable.

Conclusion

FES can occur during nailing even in a stable patient with an isolated open tibial fracture. This case report involved the knowledge gained from several clinical medical specialties, including traumatology, anesthesiology, neumology, and intensive care. Anyone involved in treating patients who present with a long bone fracture and sudden respiratory impairment should keep in mind the possibility of FES.

Consent

Written informed consent was obtained from the patient for publication of this case report and accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.

Abbreviations

CT:

Computed tomography

FES:

Fat embolism syndrome

ICU:

Intensive care unit

ISS:

Injury severity score

NISS:

New injury severity score.

References

  1. Gurd AR, Wilson RI: The fat embolism syndrome. J Bone Joint Surg (Br). 1974, 56B: 408-416.

    CAS  Google Scholar 

  2. Robinson CM: Current concepts of respiratory insufficiency syndromes after fracture. J Bone Joint Surg (Br). 2001, 83: 781-791. 10.1302/0301-620X.83B6.12440.

    Article  CAS  Google Scholar 

  3. Georgopoulos D, Bouros D: Fat embolism syndrome: clinical examination is still the preferable diagnostic method. Chest. 2003, 123: 982-983. 10.1378/chest.123.4.982.

    Article  PubMed  Google Scholar 

  4. Kallina C, Probe RA: Paradoxical fat embolism after intramedullary rodding. J Orthop Trauma. 2001, 15: 442-445. 10.1097/00005131-200108000-00011.

    Article  Google Scholar 

  5. Shaikh N, Parchani A, Bhat V, Kattren MA: Fat embolism syndrome: clinical and imaging considerations: case report and review of literature. Indian J Crit Care Med. 2008, 12: 32-36. 10.4103/0972-5229.40948.

    Article  PubMed  PubMed Central  Google Scholar 

  6. Sara S, Kenyhertz G, Herbert T, Lundeen GA: Fat emboli syndrome in a nondisplaced tibia fracture. J Orthop Trauma. 2011, 25: e27-e29. 10.1097/BOT.0b013e31820bbafb.

    Article  PubMed  Google Scholar 

  7. Bhalla T, Sawardekar A, Klingele K, Tobias J: Postoperative hypoxemia due to fat embolism. Saudi J Anaesth. 2011, 5: 332-334. 10.4103/1658-354X.84115.

    Article  PubMed  PubMed Central  Google Scholar 

  8. Pape HC, Grimme K, Van Griesven M, Sott AH, Giannoudis P, Morley J, Roise O, Elligsen E, Hildebrand F, Wiese B, Krettek : Impact of intramedullary instrumentation versus damage control for femoral fractures on inmunoinflammatory parameters: prospective randomized analysis by the EPOFF study group. J Trauma. 2003, 55: 7-13. 10.1097/01.TA.0000075787.69695.4E.

    Article  PubMed  Google Scholar 

  9. Gustilo RB, Mendoza RM, Williams DM: Problems in the management of type III (severe) open fractures. A new classification of type III open fractures. J Trauma. 1984, 24: 742-746. 10.1097/00005373-198408000-00009.

    Article  PubMed  CAS  Google Scholar 

  10. Müller ME, Koch P, Nazarian S, Schatzker J: The comprehensive classification of fractures of long bones. 1990, Berlin: Springer-Verlag

    Book  Google Scholar 

  11. Baker SP, O´Neill B, Haddon Jr Long WB: The injury severity score: a method for describing patients with multiple injuries and evaluating emergency care. J Trauma. 1974, 14: 187-196. 10.1097/00005373-197403000-00001.

    Article  PubMed  CAS  Google Scholar 

  12. Osler T, Baker SP, Long W: A modification of the injury severity score that both improves accuracy and simplifies scoring. J Trauma. 1997, 43: 922-925. 10.1097/00005373-199712000-00009.

    Article  PubMed  CAS  Google Scholar 

  13. Pape HC, Aufm Kolk M, Paffrath T, Regel G, Sturm JA, Tscherne H: Primary intramedullary fixation in polytrauma patients with associated lung contusion – a cause of posttraumatic ARDS?. J Trauma. 1993, 34: 540-545. 10.1097/00005373-199304000-00010.

    Article  PubMed  CAS  Google Scholar 

  14. Giannoudis PV, Tan HB, Perry S, Tzioupis NK, Kanakaris NK: The systemic inflammatory response following femoral canal reaming using the reamer-irrigator-aspirator (RIA) device. Injury. 2010, 41: S57-S61.

    Article  PubMed  Google Scholar 

  15. Cox G, Jones E, McGonagle D, Giannoudis PV: Reamer-irrigator-aspirator Indications and clinical results: a systematic review. Int Orthop. 2011, 35: 951-956. 10.1007/s00264-010-1189-z.

    Article  PubMed  PubMed Central  Google Scholar 

  16. Pape HC, Tornetta P, Tarkin I, Tzioupis C, Sabeson V, Olson SA: Timing of fracture fixation in multitrauma patients: the role of early total care and damage control surgery. J Am Acad Orthop Surg. 2009, 17: 541-549.

    PubMed  Google Scholar 

Download references

Acknowledgments

We thank Dr. Cardoso for her contribution to the conception of this case report. No source of funding was obtained for any author.

Author information

Authors and Affiliations

Authors

Corresponding author

Correspondence to Gustavo Aparicio.

Additional information

Competing interests

The authors declare that they have no competing interests.

Authors’ contributions

GA made substantial contributions to the conception and design of this study, including collection of data, literature review, analysis, and drafting the manuscript. IS participated in the design of this study and helped draft the manuscript. LL-D contributed to the conception and participated sufficiently in the work to take responsibility for the content. All of the authors read and approved the final manuscript.

Authors’ original submitted files for images

Rights and permissions

This article is published under license to BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly credited. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Aparicio, G., Soler, I. & López-Durán, L. Fat embolism syndrome after nailing an isolated open tibial fracture in a stable patient: a case report. BMC Res Notes 7, 237 (2014). https://doi.org/10.1186/1756-0500-7-237

Download citation

  • Received:

  • Accepted:

  • Published:

  • DOI: https://doi.org/10.1186/1756-0500-7-237

Keywords