Fat Embolism Syndrome Complicated by Acute Pulmonary Thromboembolism after Bilateral Femoral Shaft Fractures: Two Nightmares in The Same Patient
Aamir Shafi*, Jawhar Ul Islam, Wani Abdul Ahad, Aariba Zahoor
Department of General Medicine, SKIMS Medical College and Hospital, Bemina, Srinagar, Jammu & Kashmir, India
Fat embolism syndrome (FES) is an uncommon but fatal complication usually in orthopedic trauma especially after a long bone fracture. A high level of suspicion should be kept in mind when a patient of long bone fracture develops hypoxia, confusion or rash in the absence of infection and other causes of respiratory failure. Concomitant FES and pulmonary thromboembolism (PTE) is a more rarer entity in comparison to FES and pulmonary thromboembolism as separate entities. There are few cases reported in literature wherein patients developed concomitant FES and pulmonary embolism. Almost in all cases fat embolism syndrome and pulmonary embolism occurred either simultaneously or pulmonary thromboembolism was complicated by FES. We report a case wherein patient initially developed FES pre-operatively which was later on complicated by acute pulmonary thromboembolism in the post-operative period.
A 23-year-old young, healthy female was brought to orthopedic emergency department with history of road traffic accident. On assessment, she had closed bilateral femoral shaft fractures (Figure 1). The fractures were immediately splinted, and she was admitted for definitive fixation. 48 hours after admission, she developed sudden and progressive shortness of breath and hypoxia with an oximetric saturation of 75% on ambient air, requiring Fio2 of 60% to maintain saturation of >94%. There was no altered sensorium, truncal rash, vision abnormality but she was febrile, restless, tachycardic and in respiratory distress. Cheat X-ray was grossly normal.
Having suffered bilateral femoral shaft fracture and subsequent immobilization, a possibility of fat embolism vs pulmonary embolism was made. Computerized tomographic Pulmonary angiogram (CTPA) was done, which showed ground glass opacities in bilateral lung fields more in the lower zones consistent with interstitial hemorrhage associated with fat embolism (Figure 2). Hemogram revealed drop of hemoglobin from 13 mg/dl to 11 mg/dl and thrombocytopenia. ESR was raised and serum fat macro globules were present fulfilling the GURD and WILSON criteria for Fat Embolism Syndrome. She was managed in ICU with oxygen support, aggressive vital monitoring, Deep vein thrombosis (DVT) prophylaxis (Enoxaparin 0.6 mg ) and intravenous methylprednisolone.
She showed progressive improvement in her oxygen saturation over a period of five days and after achieving hemodynamic stability, she was subjected to fixation of fractures under spinal anesthesia and immediate post-operative course remained uneventful.
Three days after internal fixation of fracture, she again developed hypoxia and was tachycardic and tachypnoeic on clinical examination. There was no fever or any new infiltrates on chest X-ray. Qualifying as high risk on Well’s PTE score CTPA was done, which showed thrombi in left interlobar artery and right lower lobe segmental branches (Figure 3a and 3b). There was no hypotension or right ventricular strain on echocardiography and cardiac biomarkers were negative. She was started on rivaroxaban 15mg BD. She showed improvement in oxygenation and was discharged after 15 days of complicated hospital course in hemodynamically stable condition on oral anticoagulation.
Figure 1a: Fracture bilateral shaft of femur; 1b: Fracture fixated with intramedullary nail
Figure 2: CT image shows ground glass opacities in bilateral lung fields (R>L)
Figure 3a: Depicting thrombus in left; 3b: Depicting thrombus in right lower interlobar artery lobe segmental
Fat embolism syndrome and pulmonary embolism are common differential diagnosis in patients of orthopedic trauma and related surgical procedures when they develop hypoxia1. However, concomitant fat embolism and pulmonary embolism are very rare. After searching extensive literature, we found only few cases of concomitant fat and pulmonary embolism. Cothren et al. reported a case of concomitant FES and pulmonary embolism in a patient with pelvic fracture2. Randelli et al. reported a case of pulmonary embolism complicated by fat embolism in a patient with bilateral femoral shaft fractures3. Shao et al. reported a case of concomitant FES and pulmonary thromboembolism with tympanic membrane perforation in a patient with tibio femoral fracture4. Ebina et al. reported a case of pulmonary thromboembolism complicated by FES in a patient with femoral shaft fracture5. Yeak et al. reported a case of fat embolism syndrome and pulmonary embolism in a patient with patent foramen ovale6. Our case describes a patient who developed initially fat embolism pre-operatively followed by acute pulmonary thromboembolism in the post-operative period.
Concomitant FES and Acute PTE are very to occur with few cases reported in literature. We present a case report in which a patient initially developed FES in pre-operative period and later on suffered mild PTE also post-operatively. We suggest that patients of orthopedic trauma who develop FES should be closely followed and monitored for the development of PTE. Whether FES is a risk factor for pulmonary thromboembolism needs to be elucidated further in large randomized studies.
FES- Fat embolism syndrome
PTE- Pulmonary thromboembolism
DVT- Deep vein thrombosis
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- Cothren CC, Moore EE, Vanderheiden T, et al. Occam’s razor is a double-edged sword: Concomitant pulmonary embolus and fat embolism syndrome. Journal of Trauma and Acute Care Surgery. 2008; 65(6): 1558-60.
- Randelli F, Capitani P, Pace F, et al. Bilateral femoral shaft fractures complicated by fat and pulmonary embolism: a case report. Injury. 2015; 46: S28-30.
- Shao J, Kong DC, Zheng XH, et al. Postoperative complications of concomitant fat embolism syndrome, pulmonary embolism and tympanic membrane perforation after tibiofibular fracture: A case report. World Journal of Clinical Cases. 2021; 9(2): 476.
- Ebina M, Inoue A, Atsumi T, et al. Concomitant fat embolism syndrome and pulmonary embolism in a patient with a femoral shaft fracture. Acute Medicine & Surgery. 2016; 3(2): 135-8.
- Dk Yeak R, Liew SK. Concomitant fat embolism syndrome and pulmonary embolism in a patient with patent foramen ovale. Acta Orthop Traumatol Turc. 2020; 54(4): 465.