Date: Tue, 2 Mar 2004 23:33:52 +0530

Subject: Fat embolism and 1 week old untreated femoral fracture

From: rajesh

25 year old male transferred in today from another hospital since he needed ventillatory support. Fracture femur junction of upper and middle third shaft. He apparently had no evidence of a chest injury. 1 week since injury (he went flying off a motorbike) and he was being treated with skeletal traction (not operated due to some technical problems at the first hospital). He developed features suggestive of fat embolism today and was sent to us. O2 saturation was 77 on air and he was ventillated by our respiratory medicine people. He is being given supportive treatmnt in the form of antibiotics,fluids, etc and is currently stable even though heart rate is still 120.

I was thinking of plating the femur. I know there is not much difference between plating and nailing in such a situation but don' want to take any risks in this slightly volatile situation. (accusations about delay in the first hospital etc flying around freely).

I am not really sure about the timing though - should I wait or just go ahead since he is ventillated anyway? Would stabilising the fracture now be a case of closing the stable door after the horse has gone?

Any suggestions would be appreciated.

Dr. K. Rajesh, MS(Orth), DipNB(Orth), FRCS, FRCS(Orth)
Consultant Orthopaedic surgeon
Lords Hospital & Cosmopolitan Hospital
Trivandrum
India.

Date: Tue, 2 Mar 2004 11:53:07 -0600

From: Adam J. Starr, M.D.

Dr Rajesh,

I think I would use the stabilization method I'm best at to fix the fracture. If I felt I could do an IM nail faster, better, with less blood loss and less OR time, then that's what I'd do. If I was better and faster using plate fixation, then I'd go with a plate.

Since the patient already has fat embolism syndrome, I would ask my trauma surgeon colleagues to help me make sure he was truly as prepared as possible for the OR. It may be that some treatment could improve his pulmonary status, or his hemodynamic status. I'd make sure the tachycardia wasn't due to a missed belly injury. His heart is racing to meet his oxygen demand - why is it having to race? What can we do to make him more fit?

Adam Starr
Dallas, Texas

Date: Tue, 2 Mar 2004 13:29:24 -0600

From: Obremskey, William T

Concerns for the delay are valid, but I would be very hesitant to do a reamed or unreamed IMN in him now if his ventilatory status is marginal. You may push him over the edge into full ARDS. Reaming a proximal fracture antegrade may increase the pulmonary load from an IMN as there is no distal exit hence the reamer acts like a piston as it goes through the isthmus. You could put an medial femoral condyle "blow hole", but I would recommend placing an Ex fix to stabilize the femur temporarily. This will slow or stop the fat emboli; can be done at bedside in ICU or OR and revised to an IMN when patient stable and improved ventilatory reserve w/in 3 weeks.

A plate can be done, but has significant blood loss and higher infection and nonunion rates than an IMN.

Bill

Date: Wed, 3 Mar 2004 16:26:20 +0530

From: rajesh

Thanks.

we don't have trauma surgeons as such so I asked the general surgeons (who deal with tummies) to have a look. Abdomen is soft, bowel sounds are present,though sluggish and they could not see anyhting significant on ultrasound. we don't have CT onsite.

His BP is 130/80 mm Hg and the heart rate is still 120. Blood culture has not come back yet(24 hrs to go)but he is afebrile and on antibiotics. urine out put is good. I have suggested a plate - relatives are not really very keen at the moment.

we are stuck. will keep you posted.

rajesh

Date: Wed, 3 Mar 2004 07:49:24 -0800

From: George Thomas

This looks like very mild FES. It will probable settle down in 3 to 4 days. You can do the fixation at that time.

George Thomas,
Chennai