Fat emboli syndrome and the orthopaedic trauma surgeon: lessons learned and clinical recommendations

Abstract

Our algorithm for managing bilateral femoral fractures prioritises early stabilisation with external fixation, staged intramedullary nailing and conversion to plate fixation if FES develops. This protocol is meant to be the basis of future investigations of optimal treatment strategies.

Incidence of Fat Embolism Syndrome in Femur Fractures and Its Associated Risk Factors over Time—A Systematic Review

“…Back in the 1950s and 1960s, the early fixation of fractures was believed to be a cause of FES [ 51 , 52 ], and the concept of patients being too sick to operate prevailed into the 1980s, leading to routinely delaying fracture fixation [ 53 ]. Subsequently, several clinical studies revealed that leaving long bone fractures unstabilized for several days dramatically increased the risk of extensive FES [ 45 , 54 , 55 ]. Therefore, several treatment principles changed towards the early stabilization of fractures, ideally within 24 to 72 h. All modern concepts of timing of surgical approaches, such as Early Total Care (ETC), Early Appropriate Care (EAC), Damage Control Surgery (DCS), and Safe Definitive Surgery (SDS), propose specific modifications in the surgical treatment in order to enable surgeons to perform fracture fixations as early as possible, some in a modified fashion [ 53 , 56 , 57 , 58 ].…”

Adolescent Fat Embolism Syndrome after Closed Tibial Shaft Fracture: Treatment with Emergent External Fixation

“…The theory of damage control orthopaedics suggests the rapid and rigid stabilization provided by external fixation is an effective bridge to definitive fixation while minimizing complications in multiply injured patients [ 18 , 19 ]. In the context of FES secondary to traumatic lower extremity long bone fracture, external fixation may play a similar “damage control” role in temporarily providing rigid fracture stability without pressurization of the intramedullary canal in order to minimize fat emboli showering and reduce the severity of FES [ 20 , 21 ].…”

Cerebral fat embolism syndrome (FES): similar cases with different outcomes

“…Pape et al ’s algorithm further emphasises the need for effective medical management in patients with FES to allow for surgical intervention 24. Operative immobilisation, ideally between 12 and 24 hours after injury, has been associated with a fivefold reduction in FES compared with delayed treatment 25. Furthermore, early fixation has been associated with shorter hospital stay and fewer pulmonary complications 25.…”

“…Operative immobilisation, ideally between 12 and 24 hours after injury, has been associated with a fivefold reduction in FES compared with delayed treatment 25. Furthermore, early fixation has been associated with shorter hospital stay and fewer pulmonary complications 25. Which surgical fixation technique is superior, however, remains controversial.…”

“…Yet, he found unreamed nails increase postoperative oxygen consumption 28. Also, with the advent of the reamer–irrigator–aspirator, Dunn et al showed that a significantly decreased fat emboli burden was detected by transoesophageal echocardiogram when compared with a conventional reamer 25. With these varying findings, no current guideline exists on which type of fixation should be used.…”