Semester 6 – Orthopedic Tutorial

Tutorial 11 - Ortho 3
Rizwan is an 18-year-old boy, was riding as a pillion with his father on a motorbike. He was
knocked down from behind by a car. He sustained an injury to his left thigh. Once at the
casualty he was diagnosed to have a close midshaft fracture of his left femur. He was
admitted to the Orthopedic ward and was planned for a surgery for his left femur the next
day. You are the doctor on call in the ward.

1)How will you monitor him in the ward?

Vital Signs: Regular monitoring of blood pressure, heart rate, respiratory rate, and
temperature to detect any changes that might indicate complications such as infection, shock,
or fat embolism.
Pain Management: Assess and manage his pain using appropriate analgesics. Pain levels can
indicate worsening of condition or complications.
Neurovascular Status: Frequent checks of the circulation, sensation, and movement (CSM) in
the injured limb to ensure there is no compromise.
Signs of Compartment Syndrome: Monitor for pain, pallor, paresthesia, paralysis, and
pulselessness, which could suggest compartment syndrome.
Respiratory Monitoring: Monitor for any signs of respiratory distress or abnormal breathing
patterns.
Wound Assessment: If there are any open wounds or surgical sites, these should be
monitored for signs of infection or poor healing

The next morning, during your ward rounds, he was noted to be a bit tachyapneic and
restless.

2)What are you worried about and why?

The symptoms of tachypnea (rapid breathing) and restlessness are concerning for possible fat
embolism syndrome (FES), which is a serious complication following fractures, particularly
of long bones like the femur. The fat particles can be released from bone marrow into the
bloodstream and lodge in the lungs, leading to respiratory distress.

3)What other signs and symptoms would you look for?

Hypoxemia: Low oxygen levels in the blood.
Petechial Rash: Small red or purple spots on the skin, typically appearing on the upper body
or conjunctiva of the eyes.
Confusion or Altered Mental Status: Due to hypoxemia or cerebral emboli. (cerebral edema)
Chest Pain or Dyspnea: Indicative of pulmonary involvement.
Fever: Though non-specific, fever can be associated with FES.

4)State and explain the 2 theories involved in fat embolism.

Mechanical Theory: Suggests that fat emboli are directly released into the bloodstream
following a traumatic event that disrupts the bone and its marrow. These emboli then travel to
the lungs, causing respiratory distress and potentially reaching the brain or other organs.
Biochemical Theory: Proposes that hormonal changes induced by trauma or sepsis stimulate
the systemic release of free fatty acids, which form fat emboli. These emboli cause similar
complications as those described in the mechanical theory.

5)What would your immediate action be for this patient?

Administer Oxygen: To manage hypoxemia and support breathing. (intubation)
Fluid Management: Ensure adequate hydration but avoid fluid overload which can exacerbate
pulmonary edema. (IV fluid)
Transfer to a Higher Level of Care: He may require ICU monitoring if symptoms suggest
FES or other severe complications.
Prepare for Diagnostic Tests: Such as chest X-ray, CT scan, or MRI to assess for pulmonary
emboli or other injuries.
Alert a Multidisciplinary Team: Including an orthopedic surgeon, a respiratory therapist, and
possibly a neurologist.

6)What are the complications following the fracture?

Hypervolemic shock (3L loss)
Fat Embolism Syndrome (FES): As discussed, fat globules may occlude small blood vessels,
primarily affecting the lungs, brain, and skin.
Deep Vein Thrombosis (DVT): Immobility following fracture increases the risk of venous
thromboembolism.
Compartment Syndrome: Increased pressure within muscle compartments can compromise
circulation and requires urgent surgery to prevent permanent damage.
Infection: Particularly if any surgical intervention is involved or if there are any open
fractures.
Delayed Union or Nonunion: Poor healing of the fracture site.
Pulmonary Complications: Including pneumonia, especially in patients who are immobilized.