Fat Embolism Syndrome in a Patient with Bilateral Tibial Fractures: Report of the Case and Review of the Literature
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Author(s)
Background: Although the original clinical
description of fat embolism syndrome (FES) dates from 1873, the
condition remains a diagnostic challenge for modern clinicians. The
syndrome is described as a serious consequence of fat emboli producing a
distinct pattern of clinical symptoms and signs. It is mainly
associated with fractures of the long-bones and the pelvis. The present
paper describes the case of a trauma patient with bilateral tibial
fractures that present the syndrome and highlights the importance of
early identification and aggressive treatment of FES which is obligatory
for the patient’s survival. Case Description: A 32 year-old man reached
the hospital as a trauma call after a road traffic accident. Clinical
examination was unremarkable with the only finding that the patient was
unable to straight leg raise and weight bear. Both shins were painful
and swollen at their middle third, while the left one was in varus and
posterior displacement. Neurovascular status of both lower extremities
was normal. Plain radiographic control (X-Rays) revealed an oblique
right tibial fracture of the mid-shaft with a distal third fibular
fracture and a comminuted fracture of the left tibia with a fracture of
the fibula at the same level. The legs were immobilised on a splint and
the decision was to treat the patient surgically. Within a few post
admission hours the haemoglobin dropped by 2.9 mg/dL, however a source
of active bleeding could not be allocated. The abdomen was soft and not
tender in palpation and the central nervous system did not present any
abnormalities. The following day the haemoglobin dropped but the new
ultrasonography control did not reveal any free abdominal fluid. Both
lower limbs were not compromised. The second post-injury day the patient
went to theatre and the right tibia was stabilised with an antegrade
nail (T2-Stryker) while the left one with an external fixation. During
the reaming process the haemoglobin dropped to 7.1 gr/dL, so he was
transfused with 3 blood units. Immediately after extubation, the patient
desaturated on air and ABG values forced the anaesthetists to intubate
him in recovery and place him in mechanical ventilation with high levels
of positive end expiratory pressure (PEEP). Symptoms subsided rapidly
and he was transferred to the IMU. Clinical image and CT scan were in
favour of fat embolism syndrome. On the fifth post-operative day the
patient was transferred back to ward and a week later he was discharged
being completely free of symptoms. Clinical Relevance: Fat embolism
syndrome is typically presented with the following triad: a) respiratory
changes; b) neurologic abnormalities; c) petechial rash. These three
constitute the major criteria described by Gurd and are pathognomonic
for the condition. The patient—described in the present case
report—developed progressively all those symptoms within the expected
period of time. The FES is a well-known pathological condition that is
well described in literature and should be familiar to those clinicians
that manage trauma patients. Diagnosing the condition can be highly
demanding since there are no laboratory investigations or radiographic
imaging techniques specific for FES. Suspicion and diagnosis can be
mainly placed based on the criteria described by Gurd, in 1970.
KEYWORDS
Cite this paper
Kosmidis, I. , Kourkoutas, K. , Bampalis, I. and
Giannakopoulos, P. (2014) Fat Embolism Syndrome in a Patient with
Bilateral Tibial Fractures: Report of the Case and Review of the
Literature. Open Journal of Orthopedics, 4, 273-284. doi: 10.4236/ojo.2014.410044.
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