Fat Embolism
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Fat embolism occurs when fat enters the bloodstream from broken bones or other injuries. It can disrupt circulation in the lungs, brain, and skin. Symptoms appear within 1-3 days and include respiratory distress, neurological changes, and a rash. Diagnosis is based on clinical criteria involving these organ systems. Treatment focuses on supportive care like oxygen supplementation, ventilation if needed, and managing complications. Outcomes have improved but risks of ARDS and cerebral edema remain.
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1) Os Odontoideum is a congenital anomaly where the odontoid process is separated from the body of C2 as a separate ossicle with no bony connection. It can be asymptomatic or cause neck pain and myelopathy.
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1. Fat embolism syndrome is a serious manifestation of fat embolism that can cause multi-system dysfunction, most commonly affecting the lungs and brain.
2. It occurs most often after long bone fractures, especially femur fractures, when fat droplets enter the bloodstream and lodge in the pulmonary capillaries or brain vasculature.
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- Risk factors include being male and between ages 5-10 years old.
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- Differential diagnosis depends on whether the condition is unilateral or bilateral.
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1) Fat embolism syndrome is a serious complication of long bone fractures that can cause multi-system organ dysfunction, most commonly involving the lungs and brain.
2) The pathophysiology involves fat globules entering the bloodstream from broken bone marrow and lodging in the pulmonary vasculature and brain. This can lead to hypoxemia, neurological changes, and petechial rashes.
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- The shoulder joint is inherently unstable due to its anatomy, relying on both passive structures like the labrum and ligaments as well as active stabilizers like muscles.
- Clinical evaluation and radiographs are used to diagnose the type of dislocation and assess for complications like fractures.
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- Trauma is the most common precipitating factor. The pathogenesis involves cellular injury, necrosis, and proliferation of fibroblasts and mesenchymal cells that form bone.
- Radiographs show calcifications and ossification developing over weeks. Histopathology shows zones of ossification.
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Osteoid osteoma
Osteoid osteoma is a benign bone tumor most common in young patients, typically causing pain worsened at night. Radiographs show a small lucent nidus surrounded by reactive sclerosis. CT precisely defines the calcified nidus. MRI demonstrates surrounding bone marrow edema. Treatment involves surgical excision or thermocoagulation of the nidus, providing effective pain relief. A multimodality imaging approach is useful to characterize the lesion and differentiate it from other causes of bone pain.
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Complex Regional Pain Syndrome (CRPS) is a chronic pain condition that causes severe pain, swelling, and changes in skin color and temperature in an extremity. It usually develops after an injury, surgery, stroke or heart attack. CRPS is diagnosed based on reported symptoms and signs observed during physical exam. Treatment requires a multifaceted approach including medications, nerve blocks, physical therapy, and psychological support, with the goal of reducing pain and improving function. Early diagnosis and treatment within the first year leads to the best outcomes.
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- 1. Fat Embolism Dr. Shubhanshu Ranjan Kushwaha Orthopedic Resident
- 2. • Clinical phenomenon • 1% to 11% • Systemic dissemination of fat emboli within the system circulation. • Fat emboli will disrupt the capillary bed and affect microcirculation, causing a systemic inflammatory response syndrome
- 3. End organ manisfestation • Skin and integumentary organ • Central nervous system • Respiratory system lungs • Eyes retina
- 4. Traumatic • Most common in patients with orthopedic trauma – Fracture of the long bones • Femur • Tibia • Pelvis – Crush injury – Massive soft tissue damage – Prolonged cardiopulmonary resuscitation – Severe burn involving more than 50% of body surface area • Non traumatic
- 5. Postoperative • Intramedullary nailing and reaming – Increased velocity in reaming – The widened gap between the nail and the cortex of the bone • Knee arthroplasty • Pelvic arthroplasty
- 6. Risk factors • Young age • Closed fractures • Multiple fractures • Prolonged conservative management of long bone fracture
- 8. Biochemical Theory • triggers a hormonal change • release of free fatty acid (FFA) and chylomicrons. • acute phase reactants, such as C-reactive protein, causes the chylomicron to coalesce and migrate. • Pneumocyte hydrolysis of fat particles generates FFA which migrate to other organs
- 9. Clinical features • Fat embolism typically within 24 to 72 hours after the initial insult. • symptoms – nonspecific – Pain related to bone fracture – Nausea – General weakness – Malaise – Difficulty breathing – Headache
- 10. Signs • Respiratory – Tachypnea – Tachycardia – Diaphoresis Skin – Petechial rash • Eye – Retinal hemorrhage • Central nervous system – Agitation from hypoxia – Restlessness – Change in mental status – Seizure – Coma
- 12. Examination • General appearance – anxious, agitated • Respiratory system – abnormal breath sound, – work of breathing, – respiratory distress or impending respiratory failure. • Cardiovascular – in beginning - blood pressure and heart rate might be high – later might suffer a cardiovascular collapse with hypotension • Central nervous system – GCS less than 8 is an indication to secure the airway and put the patient on mechanical ventilation. – arise from cerebral edema rather than from cerebral ischemia. • Skin – petechial rash axilla neck nape of neck • Eye – Petechie in lower eyelids retinal hemorrhage.
- 13. Evaluation • Gurd et al. in 1970 and modified by Wilson in 1974 – two major criteria – or at least one major criteria and four minor criteria.
- 14. Criteria • Major Criteria – Petechial rash – Respiratory insufficiency – Cerebral involvement in non-head injury patients • Minor Criteria – Fever greater than 38.5 C – Tachycardia heart rate greater than 110 beats per minutes – Retinal involvement – Jaundice – Renal signs – Anemia – Thrombocytopenia – High erythrocyte sedimentation rate – Fat macroglobulinemia
- 15. • Schoenfeld Criteria – A cumulative score greater than five is required for the diagnosis. – 5 points - petechiae rash – 4 points - diffuse infiltrate on x-ray – 3 points - hypoxemia – 1 point (for each) - fever, tachycardia, confusion • Lindeque Criteria – Sustained Pa02 less than 8 kilopascal – Sustained PC02 greater than 7.3 kilopascal – Sustained respiratory rate greater than 35 breaths per minute despite sedation – Dyspnea, increased work of breathing, anxiety, tachycardia
- 16. Investigation • Complete blood count – Anemia and thrombocytopenia • Metabolic acidosis, increased level of BUN, and creatinine can be seen • Arterial blood gas – Ventilation-perfusion mismatch is a hallmark • Bronchoalveolar Lavage – diagnostic tool for fat embolism syndrome.
- 17. Imaging • Chest x-ray – Diffuse interstitial marking – Pulmonary edema – Lung infiltrate – Flake-like pulmonary marking (snowstorm appearance) • In MRI Lesions seen in brain – Centrum semi vale, – Subcortical white matter – Ganglionic regions – Thalamus
- 18. Management • Supportive care adequately oxygenating the end organs. • Goals of Supportive Care • Provision of adequate oxygenation and ventilation • Maintenance of adequate hemodynamic stability • Transfusion of packed red blood cells to improve oxygen delivery if indicated • Prophylaxis of deep venous thrombosis with a sequential compression device • Adequate nutrition and hydration
- 19. • No specific treatment • Corticosteroids • Heparin • Inferior Vena Cava Filter prophylactic • Operative Measures – early open reduction and internal fixation of long bone fractures
- 20. • techniques in orthopedic surgery to reduce embolization include: • Lavage of bone marrow prior to fixation • Venting of the femoral bone • Drilling of small holes in the cortex of the bone to lower intramedullary pressure
- 21. • For Cerebral edema – Mannitol – Hypertonic saline – Intracranial pressure monitors • Albumin is restores intravascular volume and helps to bind free fatty acid.
- 22. Indications for Intubation • Altered mental status with Glasgow coma score of less than 8 • Moderate to several respiratory distresses with no improvement on noninvasive support
- 23. • Mortality has decreased with advances in supportive care and is <10% • most common cause of morbidity or mortality include: – Acute respiratory distress syndrome ARDS – Cerebral edema
Editor's Notes
- Elevation of the intramedullary from trauma or surgery leads to the release of fat into the venous sinusoids. From the venous system, these fat globules are deposited in the pulmonary capillary bed where they travel to the brain via the arteriovenous shunt into the brain Intravascular fat droplets are deformable, hence their ability to transverse the pulmonary vasculature. Elevated pulmonary artery pressure Impairment of oxygen exchange from ventilation-perfusion mismatch Systemic effects on end-organs such as the brain, kidney, and skin. In brain systemic inflammatory response syndrome, local inflammation, Ischemia Release of inflammatory mediators and vasoactive amines like histamine, serotonin leads to an increase in vascular permeability and vasodilation causes hypotension and hypoperfusion.