Fat Embolism Syndrome

and Fractures Stabilization

Stabilization.

Dr Eli P
D Peled
l d
Orthopaedic B Department
Rambam Health Care Campus
 FES definition
FES-definition
• clinical recognition in the first several days
after longg bone fracture,, trauma,, IMN or
orthopedic surgery.
• Dyspnea
• Cognitive dysfunction
• Petechia
• appear in 46-60% in the firs 24 hours, 91% in
the first 3 days.
y
• Zenker,1861, fat drorplets in the lungs after
thoraco abdominal contusion
thoraco-abdominal contusion.
• 1873 clinically description of FE after femoral
fracture.
fracture
• Kuntscher,1950, fat spreading during IMN.
 FES -general
general
• Associated severe trauma – long bones,
pelvic and blunt trauma.
p
• Among young patients mostly between 18-
30 years.
years
• More in closed than in open fracture.
• Increased medullary canal pressure can
be a triggering factor.
factor
 Incidence

• 0.9%
0.9%-2.2%
2.2% in long bone fractures.
• 0.5%-0.8% After orthopedic procedures.
 FES associated with
• F
Fatt droplets
d l t in i fracture
f t hematoma
h t and d
blood stream.
• Clamping the femoral vein prevent lung
p
embolism after experimental femoral
fracture.
• After experimental fracture
fracture, medullary cells
are found in the lung.
• Spongiosa particles are fofound
nd in the llung
ng
after fracture and orthopedic surgery.
Bone fragment embolism Fat embolism
 Pathogenesis
g

• Mechanical- vasculature obstruction.

• Biochemical-
Biochemical ffree FA toxicity
t i it .

• The etiology remain poorly uderstood

 DIAGNOSIS
• Hi
Highh suspicion
i i ratet
• Pulmonary symptoms
tachypnea hypoxemia,
tachypnea, hypoxemia hypocapnia,
hypocapnia tachycardia.
tachycardia
• CNS symptoms
Impaired high cortical function
function.
Confusion, restlessness, somnolence, stupor or even
coma.
• Petechia
neck, axilla, shoulder, upper chest, oral mucosa and
conjunctiva- consider pathognomonic.
• Fever
U tto 39 very common early
Up l sign.
i
 Gurd & Wilson criteria
Major Minor
Petechia Tachycardia
y >110
Hypoxia Pyrexia >38.5
CNS changes Visible retina emboli
Pulmonary edema Urine fat
Sputum fat
Low PLT or Hb
Elevated ESR
At least one major & four minor criteria
 Therapy
• Fracture stabilization: prophylactic
& therapeutic
therapeutic.
• Aggressive
gg pulmonary
p y support:
pp
nasal oxygen administration, intubation
and PEEP ventilation .
• CVS resuscitation
 Therapy

• Metabolic support: Glucose and Insulin

iin order
d tto counteract
t t adrenalin
d li mobilization
bili ti off
lipids & preventing lipolysis.
• Heparin: administration in order to lessen the
thrombosis- controversial.
 MORTALITY

• Between 13% 13%-87%.

87%.
• Difficult to asses because of comorbidities.
F
Fracture
t fixation
fi ti & FES
 General
• IMN is the treatment of choice for femoral
& tibial diaphyseal fractures
fractures.
• Volume deficit, shock, lung contusion and
pre-existing pulmonary impairments can
precipitate
p p FE or FES.
 Fixation timing

• Fixation within 24 h avoids bone marrow cavity

contents extravasation [Wenda 1995].
• Decreasing time delay for fracture management
management,
is probably the most effective prophylactic mean.
• Early fixation reduce post trauma respiratory
complications [Robinson 2003].
• Fat embolism,
embolism if present,
present worsened after
surgery [Bouffard 1984].
 Medullary nailing

• Bone medullary composed of bone marrow

and blood refilled after each reaming
reaming, which
passes into circulation following each
reaming [Wenda 1996].
1996]
• Extravasations bone marrow content occurs
d i reaming
during i and d nailing
ili iinsertion
ti [W[Wozasek k
1994].
• Increased pulmonary resistance and
intravenous fat were found during g reamingg of
the medullary canal [Joist 2003].
 Chest trauma and IMN

• Presence of chest trauma is not a

contraindication for IMN.
• The risk for FE or FES is increased
[Bonnevialle 2000].
2000]
 Medullary pressure
• IM causes hihigher
h iincreases iin IM pressure and
d more ffatt and
d
bone marrow embolisation than extramedullary ones.
• Medullary peak pressure occurs during intramedullary
nailing [Strumer 1980].
• Plating
g associate with minimal ppulmonaryy changes
g
[Schemitsch1997].
• Extramedullary fixation cause minimal differences in the
pulmonary hemodynamic response even in the presence of
thoracic trauma [Neudeck 1996].
 The medullary reamer
• Reamer construction affect IM pressure [Pape 1994].
1994]
• Blunt reamer create higher pressure than sharp [Muller 1993].
• Rinsing Suction Reamer compare to the AO causes minimal
systemic changes during IMN stages [Joist 2004].
• Reaming with a smaller reamer and modified reaming lessen
IM pressure and reduces fat intravasation.
• Pressure during rode guide insertion is highest [Estebe 1997].
 RFM vs UFN
• Lower pressure increases were associated with
unreamed nailing compared to reamed nailing [Heim
1994].
1994]
• Reaming should be done at a low driving speed and a
g revolution rate using
high g a small cored reamer head,
especially during the first reaming steps
[Mousavi et al 2000].
• Reamer
R and
d nailil iinsertion
ti velocity,
l it th
the gap b
between
t
bone cortices determine the amount of embolized
material.
 RFM vs UFN
• Same pulmonary changes were found during
reamed and undreamed IM nailing [Buttaro
2002].
• Both UFN & RFN generate emboli during
femoral nailing [Coles 2000].
• UFN reduced the risk for FE or FES, lessen the
amount of blood loss and less time consuming
[Broos 1997].
 UFN
• Massive PE and death during UFN of femoral
fracture [Assal 2000, Peter et al 1997].
 Canal venting

• Maximal pressure and duration decreased more

than 50% with Venting of the medullary canal
[Roth 2004].
2004]
• Venting increased metastatic spreading.
• Distal venting is superior to proximal [Martin
1996].
 Summary

• Primary reamed IM nailing should be done

after resuscitation [Mousavi 2002].
• Stable patients can be treated with IM
nailing, preferred undreamed nail [Wenda
1997].
 Summary
• R
Reamingi iin llow d
driving
i i speedd and
d hi
high
h
revolutions per minute with a smaller
cored reamer minimize the risk of
pulmonary dysfunction especially during
the first reaming steps [Mousavi 2000 &
2002].
• Rinsing Suction Reamer cause minimal
systemic changes during IMN stages [Joist
2004].
• Initial temporary fixation and secondary
conversion to a definitive procedure has recently
been advocated, and the term "damage control
orthopaedic ssurgery"
rger " was
as coined [Pape &
Krettek 2003].
• Multitrauma patients in shock with unstable
circulation should be stabilized primarily by
EXTERNAL FIXATION. After stabilization early
changes to intramedullary nailing.