Case Report: Fat Embolism Syndrome – Grave Handicap after Traumatic Long-bones Fractures

Česká verzia

Authors: M. Blažek; E. Havel; J. Cerman; E. Bělobrádková; T. Dědek; I. Počepcov
Authors place of work: Chirurgická klinika, Univerzita Karlova v Praze, Lékařská fakulta v Hradci Králové a Fakultní nemocnice Hradec Králové, přednosta: prof. MUDr. Alexander Ferko, CSc.
Published in the journal: Rozhl. Chir., 2009, roč. 88, č. 11, s. 649-655.
Category: Monothematic special - Original

Summary

Embolism of fat and bone marrow tissue is quite often due to bone fractures but it is seldom with signs of systemic involvement as a fat embolism syndrome. The main forming factor is late stabilization of fractures and hypovolemia too. Clinical image of fat embolism syndrome results from lung and systemic microembolism which leads to activation of inflammatory and thrombogenic cascades. We present a case report of a 24-year-old male after bike accident in low speed suffering from isolated thighbone fracture – osteosynthesis was applied in 6 hours after injury. The very first day the organ failure and coma with negative CT occurred, then ARDS, petechiae into the skin of chest and conjunctiva, also embolic closure of a. centralis retinae. Treatment interventions included anticoagulation, steroids, artificial ventilation for 17 days. After 3 weeks from injury he was still unconscious (with GCS 10) so that we tried a hyperbaric oxygen therapy. The patient regained consciousness after 3 months after injury. One year later he is able to walk alone, he has no visual failure, but he is still quadruspastic although able to manipulate with a mobile phone. We discuss diagnostic criteria and treatment. We also point out need of volumetherapy in prevention of fat embolism syndrome – this was underrated here because of primary missed out diagnose of co-existing tibia fracture at the same time (this was stabilised 18 hours after injury).

Key words:
fat embolism syndrome – trauma

Zdroje

1. Talbot, M., Schemitsch, E. H. Fat embolism syndrome: history, definition, epidemiology. Injury, 2006, Oct; 37 Suppl 4: S3–7.

2. Müller, C., Rahn, B. A., Pfister, U., Meinig, R. P. The incidence, pathogenesis, diagnosis, and treatment of fat embolism. Orthop. Rev., 1994 Feb; 23(2): 107–117.

3. Shaikh, N. Emergency management of fat embolism syndrome. J. Emerg. Trauma Shock., 2009 Jan; 2(1): 29–33.

4. Lindeque, B. G., Schoeman, H. S., Dommisse, G. F., Boeyens, M. C., Vlok, A. L. Fat embolism and the fat embolism syndrome. A double-blind therapeutic study. J. Bone Joint Surg. Br., 1987 Jan; 69(1): 128–131.

5. Hulman, G. Pathogenesis of non-traumatic fat embolism. Lancet, 1988 Jun 18; 1(8599): 1366–1367. Review.

6. Guardia, S. N., Bilbao, J. M., Murray, D., Warren, R. E., Sweet, J. Fat embolism in acute pancreatitis. Arch. Pathol. Lab. Med., 1989 May; 113(5): 503–506.

7. Shapiro, M. P., Hayes, J. A. Fat embolism in sickle cell disease: Report of a case with brief review of literature. Arch. Intern. Med., 1984; 14: 181–182.

8. Orvar, K., Johlin, F. C. Atheromatous embolization resulting in acute pancreatitis after cardiac catheterization and angiographic studies. Arch. Intern. Med., 1994 Aug 8; 154(15): 1755–1761.

9. Fernández Suárez, F. E., García Arango, M. B., Quintela Baizán, A. F., Hernández Bujedo, M., Fernández Miranda, A., Ordiz Gómez, T. Multiple cholesterol athero-embolisms after resection of an abdominal aortic aneurysm. Rev. Esp. Anestesiol. Reanim., 2000 Dec; 47(10): 485–488.

10. Glossing, H. R., Pellegrini, V. D. Jr. Fat embolism syndrome: A review of pathology and physiological basis of treatment. Clin. Orthop. Relat. Res., 1982; 165: 68–82.

11. Baker, P. L., Paxel, J. A., Pettier, L. F. Free fatty acids, catecholamine and arterial hypoxia in patients with fat embolism. J. Trauma, 1971; 11: 1026–1030.

12. Gurd, A. R. Fat embolism: an aid to diagnosis. J. Bone Joint Surg. Br., 1970, 52-B: 732–737.

13. Gurd, A. R., Wilson, R. I. The fat embolism syndrome. J. Bone Joint Surg Br., 1974; 56: 408–416.

14. Schonfeld, S. A., Ploysongsang, Y., DiLisio, R., Crissman, J. D., Miller, E., Hammerschmidt, D. E., et al. Fat embolism prophylaxis with corticosteroid: A prospective study in high-risk patients. Ann. Int. Med., 1983; 99: 438–443.

15. Lindeque, B. G., Schoeman, H. S., Dommissen, G. F., Boeyens, M. C., Vlok, A. L. Fat embolism syndrome: A double blind therapeutic study. J. Bone Joint Surg. Br., 1987; 69: 128–131.

16. Alho, A. Fat embolism syndrome, Etiology pathogenesis and treatment. Acta Chir. Scand., 1980; 499: 75–85.

17. van den Brande, F. G., Hellemans, S., De Schepper, A., De Paep, R., Op De Beeck, B., De Raeve, H. R., et al. Post-traumatic severe fat embolism syndrome,with uncommon CT fi ndings. Anaesth. Intensive Care, 2006; 34: 102–106.

18. Stoeger, A., Daniaux, M., Feiber, S., Stockhammer, G., Aichner, F., zur Nedden, D. MRI finding in cerebral fat embolism. Eur. Radiol., 1998; 8: 1590–1593.

19. Suzuki, S., Hayashi, T., Ri, K., Hashimoto, T., Matsui, S., Kitanosono, T., Munechika, H., Hishida, T., Ohbuchi, M., Takizawa, K., Kuniyasu, Y., Osakabe, Y. Brain CT and MRI findings in fat embolism syndrome. Nippon Igaku Hoshasen Gakkai Zasshi, 1996 May; 56(6): 390–398.

20. Wenda, K., Runkel, M., Degrief, J., Ritter, G. Pathogenesis and clinical relevance in medullary nailing demonstrated by intra-operative echocardiography. Injury, 1993; 24: S73–81.

21. Vedrinne, J. M., Guillaume, C., Gagnieu, M. C., Gratadour, P., Fleuret, C., Motin, J. Bronchoalveolar lavage in trauma patients for diagnosis of fat embolism syndrome. Chest, 1992; 102: 1323–1327.

22. Jawed, M., Naseem, M. An update on fat embolism syndrome. Pak. J. Med. Sci., 2005; 21: 2–6.

23. Enneking, F. K. Cardiac arrest during total knee replacement. J. Clin. Anaesth., 1995; 7: 253–263.

24. Shier, M. R., Wilson, R. F., James, R. E., Riddle, J., Mammen, E. F., Pedersen, H. E. Fat embolism prophylaxis: a study of four treatment modalities. J. Trauma, 1977; 17: 621–629.

25. Stoltenberg, J. J., Gustilo, R. B. The use of methylprednisolone and hypertonic glucose in the prophylaxis of fat embolism syndrome. Clin. Orthop., 1979; 143: 211–22l.

26. Swartz, S. L., Dluhy, R. G. Corticosteroids: clinical pharmacology and therapeutic use. Drugs, 1978; 16; 238–255.

27. Szabó, G., Serinyi, P., Kocsir, L. Fat embolism: fat absorption from the site of injury. Surgery, 1963; 54: 756–760.

28. Hu, S. L., Hu, R., Li, F., Liu, Z., Xia, Y. Z., Cui, G. Y., Feng, H. Hyperbaric oxygen preconditioning protects against traumatic brain injury at high altitude. Acta Neurochir. Suppl., 2008; 105: 191–196.

29. Qin, Z., Hua, Y., Liu, W., Silbergleit, R., He, Y., Keep, R. F., Hoff, J. T., Xi, G. Hyperbaric oxygen preconditioning activates ribosomal protein S6 kinases and reduces brain swelling after intracerebral hemorrhage. Acta Neurochir. Suppl., 2008; 102: 317–320.

30. Khiabani, K. T., Bellister, S. A., Skaggs, S. S., Stephenson, L. L., Nataraj, C., Wang, W. Z., Zamboni, W. A. Reperfusion-induced neutrophil CD18 polarization: effect of hyperbaric oxygen. J. Surg. Res., 2008 Nov; 150(1): 11–16.

31. Voigt, C., Förschler, A., Jaeger, M., Meixensberger, J., Küppers-Tiedt, L., Schuhmann, M. U. Protective effect of hyperbaric oxygen therapy on experimental brain contusions. Acta Neurochir. Suppl., 2008; 102: 441–445.

32. Henninger, N., Küppers-Tiedt, L., Sicard, K. M., Günther, A., Schneider, D., Schwab, S. Neuroprotective effect of hyperbaric oxygen therapy monitored by MR-imaging after embolic stroke in rats. Exp Neurol., 2006 Oct; 201(2): 316–323.

33. Higgins, A. C., Pearlstein, R. D., Mullen, J. B., Nashold, B. S. Jr. Effects of hyperbaric oxygen therapy on long-tract neuronal conduction in the acute phase of spinal cord injury. J. Neurosurg., 1981 Oct; 55(4): 501–510.

34. Asamoto, S., Sugiyama, H., Doi, H., Iida, M., Nagao, T., Matsumoto, K. Hyperbaric oxygen (HBO) therapy for acute traumatic cervical spinal cord injury. Spinal Cord, 2000 Sep; 38(9): 538–540.

35. White, T., Petrisor, B. A., Bhandari, M. Prevention of fat embolism syndrome. Injury, 2006 Oct; 37 Suppl 4: S59–67.

36. Behrman, S. W., Fabian, T. C., Kudsk, K. A., Taylor, J. C. Improved outcome with femur fracture: Early VS delayed fixation. J. Trauma, 1990; 30: 792–797.

37. Wheelwright, E. F., Byrick, R. J., Wigglesworth, D. F., Kay, J. C., Wong, P. Y., Mullen, J. B., et al. Hypotension during cemented arthoplasty, relationship with cardiac output and fat embolism. J. Bone Joint Surg. Br., 1993; 75: 715–723.

38. Wong, M. V., Taji, H. F., Young, S. H., Chan, K. M., Cheng, J. C. Continuous pulse oximeter, for in apparent hypoxemia after long bone fractures. J. Trauma, 2004; 56: 356–362.

39. Wenda, K., Runkel, M. Systemic complications in intramedullary nailing. Orthopade, 1996 Jun; 25(3): 292–299.

40. Kallina IV, C., Probe, R. Paradoxical fat embolism after intramedullary rodding: a case report. J. Orthop. Trauma, 2001 Aug; 15(6): 442–445.

41. Riska, E. B., Myllynen, P. Fat embolism in patients with multiple injuries. J. Trauma, 1982 Nov; 22(11): 891–894.

42. Kim, K. C., Hwang, D. S., Shin, H. D. Post-traumatic cerebral fat embolism prior to operative repair of femoral and tibial fractures. Orthopedics, 2008 Feb; 31(2): 170.

43. Bouaggad, A., Harti, A., Barrou, H., Zryouil, B., Benaguida, M. Tetraplegia in fat embolism Ann. Fr. Anesth. Reanim., 1994; 13(5): 730–733.

44. Nikolič, S., Micič, J., Savič, S., Gajič, M. Factors which could affect the severity of post-traumatic pulmonary fat embolism: A prospective histological study. Srp. Arch. Celok Lek., 2003; 131: 244–248.