Fat embolism syndrome following long bone fractures

During the period August, 1979 to December, 1992, 14 patients with the fat embolism syndrome (FES) were admitted to the University Hospital of the West Indies (UHWI). Two were females and 12 males, their ages ranging from 18 to 78 years, with a median age of 23.5 years. All had lower limb long bone fractures. Clinical features included fever, tachypnoea, confusion and drowsiness. They were all hypoxaemic; 9 required Intensive Care Unit (ICU) admission and, of these 4 needed ventilatory support. Five patients became comatose, 4 of whom developed decerebrate posturing. There was one death from Klebsiella septicaemia, and 13 patients recovered fully. The FES is a serious life-threatening complication of long bone fractures whether simple or compound, usually occurring within 72 hours of the injury. A high index of suspicion is needed for its prompt detection, and early attempts at maintaining adequate tissue oxygenation most be instituted if serious neurological complications and death are to be avoided. (AU)

Fat embolism in Trinidad and Tobago - abstract

The fat embolism syndrome is under-diagnosed because of low suspicion and this study was done to increase physician awareness and improve management. In the 6 years, 1984-1989 at San Fernando General Hospital, Trinidad, there were 10 cases - 1,2,2,1,1 and 3 in the years, respectively. Six were in the 3rd decade and all male, motor vehicle accidents accounted for 9 and a fall for one. There was poor attention to on-site immobilisation and sometimes delay in patients' transfer to hospital. Diagnosis was usually made on the 2nd or 3rd day. Eight patients had femoral fractures, one a bilateral, one a tibial and one a radial fracture. Soft tissue injury was common. Symptoms were alteration in level of consciousness in 9 with progression to coma in 3. Four had respiratory distress, 8 had conjunctival petechial haemorrhages, 3 respiratory crepitations and rhonchi and 2 tachycardia. Six had elevated temperature profile and gm/100ml haemoglobin was less than 10 and haematocrit less than 30 ml/100 ml in 4. Platelet count was normal in 6 tested. Treatment was with oxygen, antibiotics and steroids (Decadron or hydrocortisone), plaster immobilisation of the tibia and radius, skeletal traction in the 6 with femoral fractures and internal Kuntschner (K-nail) fixation was done in 5 at 12-19 days post injury. One had early K-nail at 12 hours post surgery. Nine showed complete recovery; however, complications of respiratory distress, siezures and renal failure resulted in one mortality. Sufficient facilities for arterial blood gasses and other parameters were not available for diagnosis and monitoring treatment. Treatment outcome was good because of aggressive management of oxygen, antibiotics and steriods. Long bone fractures need to be fixed early to reduce the incidence of fat embolism (AU)

The operative treatment of the patellar fracture by a sound technique - abstract

For many many years the operation for patellar-fracture has been a matter of discussion - perhaps because of the fact that the surgeons tried to repair the fracture instead of repairing the extensor-function. It seems to be scarcely possible to treat this fracture and reach consolidation in a satisfactory way and surgeons have tried to use all kind of material for fixation of the fragments without success. The treatment of this problem should not be directed towards the healing of the fracture, but should be towards the elimination of the fracture by excision of the smallest part, and in case of communitative fractures the subperiostal excision of all fragments but one. It is about 1936 that Dr. Hustinx proposed this way of treatment. We have treated 25 cases of patellar-fractures from 1959 till now, following a special technique to reconstruct the extensor-apparatus, and using a frontal perforation of the remaining patellar-fragment. After suturing with interrupted catgut chromium, security is ensured by passing twice a tobacco-bag strong chromium catgut around the whole interruption in the extensor apparatus and through the hole perforated in the remaining fragment of the patella. If this is completed it is possible to mobilize the patient with plaster (pipe) after 24 hours. In this way there will be no obvious wasting of the musculature and if the plaster is removed in 3 or 4 weeks restoration of function of the knee, can be easily achieved in 3 or 4 weeks. It is only exceptional that it takes a long time to reach a 90 degree flexion of the knee. We feel that because of the good results we have obtained in the past ten years, we should recommend this technique as a routine way for treatment of this affection (AU)

Current practice in orthopaedics: compound fractures

Damage to soft tissues takes priority over bony damage in the treatment of compound fractures. Bony displacement can always be corrected later but the soft tissues must be cleansed and closed early - preferably by skin grafting. The duration of invalidism and the quantity of medical and nursing attention required is inversely proportional to the speed and thoroughness of initial treatment (AU)