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Bilateral femoral shaft fractures complicated by fat and pulmonary embolism: a case report
Injury, Int. J. Care Injured 46 S7 (2015) S28–S30
Contents lists available at ScienceDirect
Injury j o u r n a l h o m e p a g e : w w w. e l s ev i e r. c o m / l o c a t e / i n j u r y
Case Report
Bilateral femoral shaft fractures complicated by fat and pulmonary embolism: a case report Filippo Randellia,*, Paolo Capitania, Fabrizio Pacea, Sara Favillaa, Claudio Galantea, Pietro Randellib a b
Hip Department, Orthopedics and Trauma II, IRCCS Policlinico San Donato, S. Donato Milanese, Milan, Italy 2nd Department of Orthopaedics and Traumatology, IRCCS Policlinico San Donato, Milan, Italy and Department of Health Sciences, Università degli Studi di Milano, Milan, Italy
KEYWORDS
ABSTRACT
bilateral femoral shaft fractures damage control orthopedics deep venous thrombosis (DVT) pulmonary embolism (PE) venous thromboembolism (VTE) fat embolism syndrome (FES)
A 25-year-old man was admitted to our hospital because of pulmonary embolism and suspected fat embolism after sustaining bilateral femoral shaft fracture. A left arm weakness, tachycardia and sudden hemoglobin drop delayed his definitive fixation with intramedullary nailing. His clinical course was further complicated by bleeding from the pin sites of the external fixators which had initially been used to temporarily stabilize his femoral fractures (clotting disturbances). A lower leg Doppler ultrasound and a new pelvic-chest CT angiography excluded any remaining thrombus, meanwhile the embolus had broken in smaller pieces, more distally. His unfractionated heparin was revised to a Low Molecular Weight Heparin at prophylactic dose. After a 10 day period and when his condition had been improved bilateral reamed nailing was performed. Although bilateral closed femoral shaft fractures should be stabilized early, fat embolism syndrome (FES) and thromboembolic events (TEV) should always be kept in mind in these patients. © 2015 Elsevier Ltd. All rights reserved.
Introduction Femoral fractures represent 13% of all adult fractures [1] and shaft fractures are 50% of these, excluding the hip [2]. Bilateral fractures are 2–7% of femoral shaft fractures and 89% of those occur following motor vehicle accidents. Bilateral femoral shaft fractures are an independent risk factor for pulmonary failure, especially in less severely injured patients, where those injuries are often underestimated when stratified with the ISS. Bilateral femoral shaft fractures have a high mortality rate (9.8% without associated injuries and 31.6% with associated injuries) [3,4]. Timing and management of bilateral shaft fractures is essential and early fracture stabilization reduces fat embolism syndrome (FES), deep vein thrombosis (DVT) and pulmonary complications [5–18]. The patient of this case report, with a bilateral femoral shaft fracture, showed signs of both complications, FES and pulmonary embolism (PE). Case report An athletic 25-year-old man, ski instructor, was hit by his truck, which had been left without handbrake on a slope, while * Corresponding author at: Corsi di Porta Vigentina 10, 20122, Milano (MI), Italy. Tel.: +390252774528; fax: +390252774312. E-mail address: [email protected] (F. Randelli). 0020-1383/© 2015 Elsevier Ltd. All rights reserved.
closing his garage. The patient was transferred to the closest hospital, 20 km away. A bilateral closed femoral shaft fracture was diagnosed (Fig. 1). There was no other evidence of associated injuries. An emergency operating theater (OR) was prepared for immediate stabilization of the fractures by intramedullary nailing. As the family refused surgery, the patient was transferred to a hospital in the nearest major town, 180 km away. The patient was admitted to the new hospital 6 hours after the original injury in good clinical condition (hemoglobin 11.0 g/dl) with fractures held in two splints. Bilateral skeletal traction was applied. Surgery (bilateral nailing) was scheduled for the morning of the second day after admission. The day after, the patient was stable and still in good condition. Two days after the accident, in the operating theater, just prior to surgery (and without any anesthetic drug) the patient became disoriented, presented a sudden weakness in his left arm, tachycardia and a sudden hemoglobin drop. Still in traction the patient was transferred immediately to an Intensive Care Unit where they received allogeneic blood transfusions. As soon as hemoglobin returned to acceptable values, the same day, the patient was brought back to the OR for bilateral stabilization with two external fixators (Fig. 2). The following day his general condition improved. A chest CT revealed a large thrombus at the pulmonary trunk bifurcation. The patient started intravenous unfractionated heparin at therapeutic dosage for pulmonary embolism (PE). Selective thrombolysis was not indicated.
F. Randelli et al. / Injury, Int. J. Care Injured 46 S7 (2015) S28–S30
S29
Fig. 1. Initial X-rays. A bilateral femoral shaft fracture (type 32-A1 on the right and type 32-A3 on the left). Fig. 3. X-rays after modification of previous external fixators. Three pins for fragment. Less grossly displaced fractures.
Fig. 4. Five month X-rays. Full healing.
Fig. 2. X-rays after first external fixators. Two fiches for fragment. Grossly displaced fractures.
The patient was then transferred to our hospital ICU 3 days later, five days after initial trauma. Oxygen saturation in air was 99% without dyspnea and without right heart involvement. Locally the patient was painful, especially at the left femur, grossly internally rotated, where, furthermore, there was continuous bleeding from the external fixator pin sites. Blood tests showed progressive blood loss. A compression bandage was applied to try to reduce this loss. In the following three days two Doppler ultrasound and a CT angiography did not show any pelvic or lower leg thrombus. A new chest CT angiography showed the embolus had broken in smaller pieces, more distally. The patient continued to be eupnoic in air but very painful. His left arm weakness decreased. The external fixator wounds continued to bleed maintaining hemoglobin value around 7.0 g/dl requiring two more allogeneic transfusions. A hematologist advised switching from unfractionated heparin to LMWH at almost prophylactic dose. Two days later, seven days after trauma, heparin was discontinued and LMWH, seleparine 0.6 ml s.c., was initiated. The day after, under ultrasound trans-esophageal control, the patient underwent readjustment of the external fixators (Fig. 3). Better reduction and stabilization of the fractures was achieved. In the post-operative period hemoglobin was stable 8.4 g/dl, the patient felt almost no pain and could be mobilized. Ten days after last surgery and eighteen days after trauma, with a C-reactive protein (CRP) falling to normal and hemoglobin still 8.7 g/dl, the patient underwent definitive stabilization with two antegrade reamed intramedullary nails. One month after the initial trauma the patient was discharged from the hospital.
He demonstrated continuous bone healing with a rapid clinical recovery. At 5 months he was radiologically healed and resumed all his daily and sporting activities (Fig. 4). Discussion The presence of bilateral femoral shaft fractures should be recognized as an increased risk for systemic complications. First, patients with bilateral femoral shaft fractures have a significantly high percentage of severe associated injuries as well as severe blood loss [19]. Second, even in the absence of acute associated injuries, fat embolism syndrome (FES) and thromboembolic events (TEV), may precipitate the clinical situation. Fat embolism (FE) is very common: found in 95% of femoral shaft fractures. Fat Embolism Syndrome (FES) in isolated femoral fracture has been reported between 1–10% [5–11] but in bilateral fractures it is suspected to be higher [10]. An external brace or cast and skeletal traction should not be considered prophylactic for preventing FES [9,12–14]. Early surgical stabilization of the fracture, within 24 hours, decreases but does not exclude a FES. FES has been described also in case of immediate nailing of a bilateral femoral fracture [15]. The unexplained disorientation and left arm weakness presented by the patient should immediately point out to the differential diagnosis of fat embolism syndrome. Asymptomatic deep vein thrombosis (DVT) is reported in 40–50% of cases whereas symptomatic in 3% (with an ISS >30 the percentage increase to 5%). Pulmonary embolism (PE) has been reported in 0.5% of cases. With correct prophylaxis DVT is reported around 0.36% and PE 0.13% [15–18]. Early surgical stabilization of the fracture (external or internal fixation), before 24 hours, dramatically decreases DVT and pulmonary
S30
F. Randelli et al. / Injury, Int. J. Care Injured 46 S7 (2015) S28–S30
complications. An external brace or cast and skeletal traction should not be considered prophylactic for DVT, PE and pulmonary complications [20,21]. Skeletal traction may be safe in this regard if a definitive nailing is scheduled before 24 hours [22]. Both in isolated and bilateral femoral shaft fractures, initial fracture fixation with intramedullary nail (IMN) results in the lowest hospital stay (days) and mortality rate. However in case of increased injury severity (New Injury Severity Score (NISS)) >40 (with major abdominal, pelvic, and chest injuries) the first appropriate method for femoral stabilization is the external fixation, consistent with the damage control orthopaedics principle. [3,23,24]. The peculiarity of this case report is represented by the concomitant signs of fat and pulmonary embolism in a still untreated patient. Furthermore, the unstable external fixator frame required modification of the fixation. Fortunately the absence of any remaining peripheral thrombus and the well tolerated disaggregating embolus allowed to proceed with revision of the external fixator frame and subsequent definitive stabilisation by nailing. The only other published case report of a concomitant pulmonary embolus and fat embolism syndrome was reported in a young male with bilateral femoral shaft fractures which were immediately nailed [25]. Conclusion Bilateral closed femoral shaft fractures should be treated with caution due to the increased risk of complications [26–28]. Skeletal traction should be avoided and is not recommended unless definitive fixation is expected within 24 hours. Intramedullary nailing remains the golden standard. If severe associated injuries are present the best initial treatment modality is temporary external fixation. Fat embolism syndrome (FES) and thromboembolic events (TEV) should be always kept in mind in these patients, even if femoral fractures are immediately stabilized. Conflict of interest The authors certify that they have no affiliations with or involvement in any organization or entity with any financial interest (such as honoraria; educational grants; participation in speakers’ bureaus; membership, employment, consultancies, stock ownership, or other equity interest; and expert testimony or patent licensing arrangements), or non-financial interest (such as personal or professional relationships, affiliations, knowledge or beliefs) in the subject matter or materials discussed in this manuscript. References [1] Court-Brown CM, Caesar B. Epidemiology of adult fractures: A review. Injury 2006;37:691–7. [2] Ng AC, Drake MT, Clarke BL, Sems SA, Atkinson EJ, Achenbach SJ, Melton LJ 3rd. Trends in subtrochanteric, diaphyseal, and distal femur fractures, 1984–2007. Osteoporos Int 2012;23:1721–6. [3] Willett K, Al-Khateeb H, Kotnis R, Bouamra O, Lecky F. Risk of mortality: the relationship with associated injuries and fracture treatment methods in patients with unilateral or bilateral femoral shaft fractures. J Trauma 2010;69:405–10. [4] O’Toole RV, Lindbloom BJ, Hui E, Fiastro A, Boateng H, O’Brien M, et al. Are bilateral femoral fractures no longer a marker for death? J Orthop Trauma 2014;28:77–81.
last page reference
[5] Gurd AR. Fat embolism: an aid to diagnosis. J Bone Joint Surg Br 1970;52:732–7. [6] Allardyce DB, Meek RN, Woodruff B, Cassim MM, Ellis D. Increasing our knowledge of the pathogenesis of fat embolism: a prospective study of 43 patients with fractured femoral shafts. J Trauma 1974;14:955–62. [7] Fabian TC, Hoots AV, Stanford DS, Patterson CR, Mangiante EC. Fat embolism syndrome: prospective evaluation in 92 fracture patients. Crit Care Med 1990;18:42–6. [8] Bulger EM, Smith DG, Maier RV, Jurkovich GJ. Fat embolism syndrome. A 10-year review. Arch Surg 1997;132:435–9. [9] Pinney SJ, Keating JF, Meek RN. Fat embolism syn- drome in isolated femoral fractures: does timing of nailing influence incidence? Injury 1998;29:131–3. [10] Kontakis GM, Tossounidis T, Weiss K, Pape HC, Giannoudis PV. Fat embolism: special situations bilateral femoral fractures and pathologic femoral fractures. Injury 2006;37(Suppl 4):S19–24. [11] Talbot M, Schemitsch EH. Fat embolism syndrome: history, definition, epidemiology. Injury 2006;37(Suppl 4):S3–7. [12] Riska EB, von Bonsdorff H, Hakkinen S, Jaroma H, Kiviluoto O, Paavilainen T. Prevention of fat embolism by early internal fixation of fractures in patients with multiple injuries. Injury 1976;8:110–6. [13] Talucci RC, Manning J, Lampard S, Bach A, Carrico CJ. Early intramedullary nailing of femoral shaft fractures: a cause of fat embolism syndrome. Am J Surg 1983;146:107–11. [14] Ten Duis HJ, Nijsten MW, Klasen HJ, Binnendijk B. Fat embolism in patients with an isolated fracture of the femoral shaft. J Trauma 1988;28:383–90. [15] Akoh CC, Schick C, Otero J, Karam M. Fat embolism syndrome after femur fracture fixation: a case report. Iowa Orthop J 2014;34:55–62. [16] Niikura T, Lee SY, Oe K, Koh A, Koga T, Dogaki Y, et al. Venous thromboembolism in Japanese patients with fractures of the pelvis and/or lower extremities using physical prophylaxis alone. J Orthop Surg (Hong Kong) 2012;20:196–200. [17] Stawicki SP, Grossman MD, Cipolla J, Hoff WS, Hoey BA, Wainwright G, Reed JF 3rd. Deep venous thrombosis and pulmonary embolism in trauma patients: an overstatement of the problem? Am Surg 2005;71:387–91. [18] Knudson MM, Ikossi DG, Khaw L, Morabito D, Speetzen LS. Thromboembolism after trauma: an analysis of 1602 episodes from the American College of Surgeons National Trauma Data Bank. Ann Surg 2004;240:490–6; discussion 496–8. [19] Kobbe P, Micansky F, Lichte P, Sellei RM, Pfeifer R, Dombroski D. Increased morbidity and mortality after bilateral femoral shaft fractures: myth or reality in the era of damage control? Injury 2013;44:221–5. [20] Nahm NJ, Como JJ, Wilber JH, Vallier HA. Early appropriate care: definitive stabilization of femoral fractures within 24 hours of injury is safe in most patients with multiple injuries. J Trauma 2011;71:175–85. [21] Bone LB, Johnson KD, Weigelt J, Scheinberg R. Early versus delayed stabilization of femoral fractures. A prospective randomized study. J Bone Joint Surg Am 1989;71:336–40. [22] Scannel BP, Waldrop NE, Sasser HC, Sing RF, Bosse MJ. Skeletal traction versus external fixation in the initial temporization of femoral shaft fractures in severely injured patients. J Trauma 2010;68:633–40. [23] Steinhausen E, Lefering R, Tjardes T, Neugebauer EA, Bouillon B, Rixen D, et al. A risk-adapted approach is beneficial in the management of bilateral femoral shaft fractures in multiple trauma patients: an analysis based on the trauma registry of the German Trauma Society. J Trauma Acute Care Surg 2014;76:1288–93. [24] Pape HC, Rixen D, Morley J, Husebye EE, Mueller M, Dumont C, et al. Impact of the method of initial stabilization for femoral shaft fractures in patients with multiple injuries at risk for complications (borderline patients). Ann Surg 2007;246:491–9; discussion 499–501. [25] Cothren CC, Moore EE, Vanderheiden T, Haenel JB, Smith WR. Occam’s razor is a double-edged sword: concomitant pulmonary embolus and fat embolism syndrome. J Trauma 2008;65:1558–60. [26] Huang S, Vohora A, Russ MK, Mathew JK, Johnny CS, Stevens J, Fitzgerald MC. Delaying urinary catheter insertion in the reception and resuscitation of blunt multitrauma and using a full bladder to tamponade pelvic bleeding. Injury 2015;46:1081–3. [27] Lichte P, Weber C, Sellei RM, Hildebrand F, Lefering R, Pape HC, et al. Are bilateral tibial shaft fractures associated with an increased risk for adverse outcome? Injury 2014;45:1985–9. [28] Kobbe P, Micansky F, Lichte P, Sellei RM, Pfeifer R, Dombroski D, et al. Increased morbidity and mortality after bilateral femoral shaft fractures: myth or reality in the era of damage control? Injury 2013;44:221–5.
Contents lists available at ScienceDirect
Injury j o u r n a l h o m e p a g e : w w w. e l s ev i e r. c o m / l o c a t e / i n j u r y
Case Report
Bilateral femoral shaft fractures complicated by fat and pulmonary embolism: a case report Filippo Randellia,*, Paolo Capitania, Fabrizio Pacea, Sara Favillaa, Claudio Galantea, Pietro Randellib a b
Hip Department, Orthopedics and Trauma II, IRCCS Policlinico San Donato, S. Donato Milanese, Milan, Italy 2nd Department of Orthopaedics and Traumatology, IRCCS Policlinico San Donato, Milan, Italy and Department of Health Sciences, Università degli Studi di Milano, Milan, Italy
KEYWORDS
ABSTRACT
bilateral femoral shaft fractures damage control orthopedics deep venous thrombosis (DVT) pulmonary embolism (PE) venous thromboembolism (VTE) fat embolism syndrome (FES)
A 25-year-old man was admitted to our hospital because of pulmonary embolism and suspected fat embolism after sustaining bilateral femoral shaft fracture. A left arm weakness, tachycardia and sudden hemoglobin drop delayed his definitive fixation with intramedullary nailing. His clinical course was further complicated by bleeding from the pin sites of the external fixators which had initially been used to temporarily stabilize his femoral fractures (clotting disturbances). A lower leg Doppler ultrasound and a new pelvic-chest CT angiography excluded any remaining thrombus, meanwhile the embolus had broken in smaller pieces, more distally. His unfractionated heparin was revised to a Low Molecular Weight Heparin at prophylactic dose. After a 10 day period and when his condition had been improved bilateral reamed nailing was performed. Although bilateral closed femoral shaft fractures should be stabilized early, fat embolism syndrome (FES) and thromboembolic events (TEV) should always be kept in mind in these patients. © 2015 Elsevier Ltd. All rights reserved.
Introduction Femoral fractures represent 13% of all adult fractures [1] and shaft fractures are 50% of these, excluding the hip [2]. Bilateral fractures are 2–7% of femoral shaft fractures and 89% of those occur following motor vehicle accidents. Bilateral femoral shaft fractures are an independent risk factor for pulmonary failure, especially in less severely injured patients, where those injuries are often underestimated when stratified with the ISS. Bilateral femoral shaft fractures have a high mortality rate (9.8% without associated injuries and 31.6% with associated injuries) [3,4]. Timing and management of bilateral shaft fractures is essential and early fracture stabilization reduces fat embolism syndrome (FES), deep vein thrombosis (DVT) and pulmonary complications [5–18]. The patient of this case report, with a bilateral femoral shaft fracture, showed signs of both complications, FES and pulmonary embolism (PE). Case report An athletic 25-year-old man, ski instructor, was hit by his truck, which had been left without handbrake on a slope, while * Corresponding author at: Corsi di Porta Vigentina 10, 20122, Milano (MI), Italy. Tel.: +390252774528; fax: +390252774312. E-mail address: [email protected] (F. Randelli). 0020-1383/© 2015 Elsevier Ltd. All rights reserved.
closing his garage. The patient was transferred to the closest hospital, 20 km away. A bilateral closed femoral shaft fracture was diagnosed (Fig. 1). There was no other evidence of associated injuries. An emergency operating theater (OR) was prepared for immediate stabilization of the fractures by intramedullary nailing. As the family refused surgery, the patient was transferred to a hospital in the nearest major town, 180 km away. The patient was admitted to the new hospital 6 hours after the original injury in good clinical condition (hemoglobin 11.0 g/dl) with fractures held in two splints. Bilateral skeletal traction was applied. Surgery (bilateral nailing) was scheduled for the morning of the second day after admission. The day after, the patient was stable and still in good condition. Two days after the accident, in the operating theater, just prior to surgery (and without any anesthetic drug) the patient became disoriented, presented a sudden weakness in his left arm, tachycardia and a sudden hemoglobin drop. Still in traction the patient was transferred immediately to an Intensive Care Unit where they received allogeneic blood transfusions. As soon as hemoglobin returned to acceptable values, the same day, the patient was brought back to the OR for bilateral stabilization with two external fixators (Fig. 2). The following day his general condition improved. A chest CT revealed a large thrombus at the pulmonary trunk bifurcation. The patient started intravenous unfractionated heparin at therapeutic dosage for pulmonary embolism (PE). Selective thrombolysis was not indicated.
F. Randelli et al. / Injury, Int. J. Care Injured 46 S7 (2015) S28–S30
S29
Fig. 1. Initial X-rays. A bilateral femoral shaft fracture (type 32-A1 on the right and type 32-A3 on the left). Fig. 3. X-rays after modification of previous external fixators. Three pins for fragment. Less grossly displaced fractures.
Fig. 4. Five month X-rays. Full healing.
Fig. 2. X-rays after first external fixators. Two fiches for fragment. Grossly displaced fractures.
The patient was then transferred to our hospital ICU 3 days later, five days after initial trauma. Oxygen saturation in air was 99% without dyspnea and without right heart involvement. Locally the patient was painful, especially at the left femur, grossly internally rotated, where, furthermore, there was continuous bleeding from the external fixator pin sites. Blood tests showed progressive blood loss. A compression bandage was applied to try to reduce this loss. In the following three days two Doppler ultrasound and a CT angiography did not show any pelvic or lower leg thrombus. A new chest CT angiography showed the embolus had broken in smaller pieces, more distally. The patient continued to be eupnoic in air but very painful. His left arm weakness decreased. The external fixator wounds continued to bleed maintaining hemoglobin value around 7.0 g/dl requiring two more allogeneic transfusions. A hematologist advised switching from unfractionated heparin to LMWH at almost prophylactic dose. Two days later, seven days after trauma, heparin was discontinued and LMWH, seleparine 0.6 ml s.c., was initiated. The day after, under ultrasound trans-esophageal control, the patient underwent readjustment of the external fixators (Fig. 3). Better reduction and stabilization of the fractures was achieved. In the post-operative period hemoglobin was stable 8.4 g/dl, the patient felt almost no pain and could be mobilized. Ten days after last surgery and eighteen days after trauma, with a C-reactive protein (CRP) falling to normal and hemoglobin still 8.7 g/dl, the patient underwent definitive stabilization with two antegrade reamed intramedullary nails. One month after the initial trauma the patient was discharged from the hospital.
He demonstrated continuous bone healing with a rapid clinical recovery. At 5 months he was radiologically healed and resumed all his daily and sporting activities (Fig. 4). Discussion The presence of bilateral femoral shaft fractures should be recognized as an increased risk for systemic complications. First, patients with bilateral femoral shaft fractures have a significantly high percentage of severe associated injuries as well as severe blood loss [19]. Second, even in the absence of acute associated injuries, fat embolism syndrome (FES) and thromboembolic events (TEV), may precipitate the clinical situation. Fat embolism (FE) is very common: found in 95% of femoral shaft fractures. Fat Embolism Syndrome (FES) in isolated femoral fracture has been reported between 1–10% [5–11] but in bilateral fractures it is suspected to be higher [10]. An external brace or cast and skeletal traction should not be considered prophylactic for preventing FES [9,12–14]. Early surgical stabilization of the fracture, within 24 hours, decreases but does not exclude a FES. FES has been described also in case of immediate nailing of a bilateral femoral fracture [15]. The unexplained disorientation and left arm weakness presented by the patient should immediately point out to the differential diagnosis of fat embolism syndrome. Asymptomatic deep vein thrombosis (DVT) is reported in 40–50% of cases whereas symptomatic in 3% (with an ISS >30 the percentage increase to 5%). Pulmonary embolism (PE) has been reported in 0.5% of cases. With correct prophylaxis DVT is reported around 0.36% and PE 0.13% [15–18]. Early surgical stabilization of the fracture (external or internal fixation), before 24 hours, dramatically decreases DVT and pulmonary
S30
F. Randelli et al. / Injury, Int. J. Care Injured 46 S7 (2015) S28–S30
complications. An external brace or cast and skeletal traction should not be considered prophylactic for DVT, PE and pulmonary complications [20,21]. Skeletal traction may be safe in this regard if a definitive nailing is scheduled before 24 hours [22]. Both in isolated and bilateral femoral shaft fractures, initial fracture fixation with intramedullary nail (IMN) results in the lowest hospital stay (days) and mortality rate. However in case of increased injury severity (New Injury Severity Score (NISS)) >40 (with major abdominal, pelvic, and chest injuries) the first appropriate method for femoral stabilization is the external fixation, consistent with the damage control orthopaedics principle. [3,23,24]. The peculiarity of this case report is represented by the concomitant signs of fat and pulmonary embolism in a still untreated patient. Furthermore, the unstable external fixator frame required modification of the fixation. Fortunately the absence of any remaining peripheral thrombus and the well tolerated disaggregating embolus allowed to proceed with revision of the external fixator frame and subsequent definitive stabilisation by nailing. The only other published case report of a concomitant pulmonary embolus and fat embolism syndrome was reported in a young male with bilateral femoral shaft fractures which were immediately nailed [25]. Conclusion Bilateral closed femoral shaft fractures should be treated with caution due to the increased risk of complications [26–28]. Skeletal traction should be avoided and is not recommended unless definitive fixation is expected within 24 hours. Intramedullary nailing remains the golden standard. If severe associated injuries are present the best initial treatment modality is temporary external fixation. Fat embolism syndrome (FES) and thromboembolic events (TEV) should be always kept in mind in these patients, even if femoral fractures are immediately stabilized. Conflict of interest The authors certify that they have no affiliations with or involvement in any organization or entity with any financial interest (such as honoraria; educational grants; participation in speakers’ bureaus; membership, employment, consultancies, stock ownership, or other equity interest; and expert testimony or patent licensing arrangements), or non-financial interest (such as personal or professional relationships, affiliations, knowledge or beliefs) in the subject matter or materials discussed in this manuscript. References [1] Court-Brown CM, Caesar B. Epidemiology of adult fractures: A review. Injury 2006;37:691–7. [2] Ng AC, Drake MT, Clarke BL, Sems SA, Atkinson EJ, Achenbach SJ, Melton LJ 3rd. Trends in subtrochanteric, diaphyseal, and distal femur fractures, 1984–2007. Osteoporos Int 2012;23:1721–6. [3] Willett K, Al-Khateeb H, Kotnis R, Bouamra O, Lecky F. Risk of mortality: the relationship with associated injuries and fracture treatment methods in patients with unilateral or bilateral femoral shaft fractures. J Trauma 2010;69:405–10. [4] O’Toole RV, Lindbloom BJ, Hui E, Fiastro A, Boateng H, O’Brien M, et al. Are bilateral femoral fractures no longer a marker for death? J Orthop Trauma 2014;28:77–81.
last page reference
[5] Gurd AR. Fat embolism: an aid to diagnosis. J Bone Joint Surg Br 1970;52:732–7. [6] Allardyce DB, Meek RN, Woodruff B, Cassim MM, Ellis D. Increasing our knowledge of the pathogenesis of fat embolism: a prospective study of 43 patients with fractured femoral shafts. J Trauma 1974;14:955–62. [7] Fabian TC, Hoots AV, Stanford DS, Patterson CR, Mangiante EC. Fat embolism syndrome: prospective evaluation in 92 fracture patients. Crit Care Med 1990;18:42–6. [8] Bulger EM, Smith DG, Maier RV, Jurkovich GJ. Fat embolism syndrome. A 10-year review. Arch Surg 1997;132:435–9. [9] Pinney SJ, Keating JF, Meek RN. Fat embolism syn- drome in isolated femoral fractures: does timing of nailing influence incidence? Injury 1998;29:131–3. [10] Kontakis GM, Tossounidis T, Weiss K, Pape HC, Giannoudis PV. Fat embolism: special situations bilateral femoral fractures and pathologic femoral fractures. Injury 2006;37(Suppl 4):S19–24. [11] Talbot M, Schemitsch EH. Fat embolism syndrome: history, definition, epidemiology. Injury 2006;37(Suppl 4):S3–7. [12] Riska EB, von Bonsdorff H, Hakkinen S, Jaroma H, Kiviluoto O, Paavilainen T. Prevention of fat embolism by early internal fixation of fractures in patients with multiple injuries. Injury 1976;8:110–6. [13] Talucci RC, Manning J, Lampard S, Bach A, Carrico CJ. Early intramedullary nailing of femoral shaft fractures: a cause of fat embolism syndrome. Am J Surg 1983;146:107–11. [14] Ten Duis HJ, Nijsten MW, Klasen HJ, Binnendijk B. Fat embolism in patients with an isolated fracture of the femoral shaft. J Trauma 1988;28:383–90. [15] Akoh CC, Schick C, Otero J, Karam M. Fat embolism syndrome after femur fracture fixation: a case report. Iowa Orthop J 2014;34:55–62. [16] Niikura T, Lee SY, Oe K, Koh A, Koga T, Dogaki Y, et al. Venous thromboembolism in Japanese patients with fractures of the pelvis and/or lower extremities using physical prophylaxis alone. J Orthop Surg (Hong Kong) 2012;20:196–200. [17] Stawicki SP, Grossman MD, Cipolla J, Hoff WS, Hoey BA, Wainwright G, Reed JF 3rd. Deep venous thrombosis and pulmonary embolism in trauma patients: an overstatement of the problem? Am Surg 2005;71:387–91. [18] Knudson MM, Ikossi DG, Khaw L, Morabito D, Speetzen LS. Thromboembolism after trauma: an analysis of 1602 episodes from the American College of Surgeons National Trauma Data Bank. Ann Surg 2004;240:490–6; discussion 496–8. [19] Kobbe P, Micansky F, Lichte P, Sellei RM, Pfeifer R, Dombroski D. Increased morbidity and mortality after bilateral femoral shaft fractures: myth or reality in the era of damage control? Injury 2013;44:221–5. [20] Nahm NJ, Como JJ, Wilber JH, Vallier HA. Early appropriate care: definitive stabilization of femoral fractures within 24 hours of injury is safe in most patients with multiple injuries. J Trauma 2011;71:175–85. [21] Bone LB, Johnson KD, Weigelt J, Scheinberg R. Early versus delayed stabilization of femoral fractures. A prospective randomized study. J Bone Joint Surg Am 1989;71:336–40. [22] Scannel BP, Waldrop NE, Sasser HC, Sing RF, Bosse MJ. Skeletal traction versus external fixation in the initial temporization of femoral shaft fractures in severely injured patients. J Trauma 2010;68:633–40. [23] Steinhausen E, Lefering R, Tjardes T, Neugebauer EA, Bouillon B, Rixen D, et al. A risk-adapted approach is beneficial in the management of bilateral femoral shaft fractures in multiple trauma patients: an analysis based on the trauma registry of the German Trauma Society. J Trauma Acute Care Surg 2014;76:1288–93. [24] Pape HC, Rixen D, Morley J, Husebye EE, Mueller M, Dumont C, et al. Impact of the method of initial stabilization for femoral shaft fractures in patients with multiple injuries at risk for complications (borderline patients). Ann Surg 2007;246:491–9; discussion 499–501. [25] Cothren CC, Moore EE, Vanderheiden T, Haenel JB, Smith WR. Occam’s razor is a double-edged sword: concomitant pulmonary embolus and fat embolism syndrome. J Trauma 2008;65:1558–60. [26] Huang S, Vohora A, Russ MK, Mathew JK, Johnny CS, Stevens J, Fitzgerald MC. Delaying urinary catheter insertion in the reception and resuscitation of blunt multitrauma and using a full bladder to tamponade pelvic bleeding. Injury 2015;46:1081–3. [27] Lichte P, Weber C, Sellei RM, Hildebrand F, Lefering R, Pape HC, et al. Are bilateral tibial shaft fractures associated with an increased risk for adverse outcome? Injury 2014;45:1985–9. [28] Kobbe P, Micansky F, Lichte P, Sellei RM, Pfeifer R, Dombroski D, et al. Increased morbidity and mortality after bilateral femoral shaft fractures: myth or reality in the era of damage control? Injury 2013;44:221–5.