NURS 7360
Unit 6
Bone Fractures/Fat Embolism Syndrome (FES)/Compartment Syndrome
Compartment syndrome is manifested by the "five Ps" and you need to memorize these:
1. Pain out of proportion
2. Paresthesia
3. Powerlessness
4. Paresthesia
5. Pulselessness
The most common sites affected are the lower leg due to tibia fractures and fractures of the
forearm associated with the radius and ulna. Compartment syndrome can also occur in the
buttocks, thigh, upper arm, hand, and foot. Recognize compartment syndrome early with
compartment pressure monitoring. Elevate the extremity to the level of the heart, release all
compressive dressings/clothing, and a fasciotomy.
Fractures
Fractures are diagnosed when a break in the bone cortex is visible on two radiographic views.
Angulated fractures refer to an open or closed fractures usually with more than 30 degrees of
angulation.
A transverse fracture is straight across the bone.
Oblique fractures are seen diagonally on x-ray films
Spiral fractures are seen as wrapping around the bone.
Impacted fractures occur when both parts of the broken bone are crushed together
A comminuted fracture is observed when the bone ends shatter into multiple fragments
A greenstick fracture is diagnosed when the bone tears as if a fresh twig were being bent in two
Osteoporosis is a preventable disease with silent bone loss and often not diagnosed until a bone
fractures. Risk factors for osteoporosis and osteoporotic fracture include a thorough history of
fracture, age (postmenopausal woman, > 70 years in men), female sex, low BMI, 10% decrease
in weight, sedentary, steroids, previous fragility fracture as an adult, white/Asian race, tobacco
use, low dietary calcium, and 3 or greater alcoholic drinks daily. Your treatment plan can include
the following: oral bisphosphonates alendronate and risedronate, zoledronic acid, raloxifene,
calcitonin, estrogen replacement therapy but not as first-line. In addition, you may consider
recommending vertebroplasty and kyphoplasty as surgical approaches for management of
vertebral compression fractures.
Review these surgical options in this video:
https://www.youtube.com/watch?v=_lUhQLFHriw
The fat embolism syndrome (FES): is associated with fat particles in the microcirculation of
the lung. You will assess the following in patients with a fat embolism:
Lung dysfunction
Petechiae rash
Neurologic symptoms: loss of consciousness, confusion, alteration in mentation, seizures, focal
deficits,
Fat embolisms are most commonly seen after a long bone fracture and patients present with
dyspnea and confusion. Fat embolism syndrome is also a major cause of acute chest syndrome in
patients with Sickle Cell Disease. After the injury, there is a latent interval of 12 to 72 hours
before the syndrome is recognized. The prominent findings are lung injury and neurologic
dysfunction.
The patient with fat embolism syndrome looks like ARDS with dyspnea, hypoxemia, and diffuse
lung lesion. The patient can also be confused, obtunded or in a coma due to cerebral fat
embolism. Neuropathologic findings include fat microemboli and diffuse petechial
hemorrhagic infarcts. Petechiae are seen on the skin over the upper chest, neck, and face in
about 50% of patients. Often thrombocytopenia and anemia are present.
Figure 1
Fat embolism
DDs
Pulmonary emboli
Amniotic fluid embolism syndrome
Tumor embolism
Foreign body embolism
Air embolism
Vasculitis disorders: SLE
Alveolar filling disorders: pneumonia, ARDS, pulmonary contusion (use the 2D echo to figure it
out!!)
Causes of fat embolism in traumatic circumstances:
1. Long bone fracture
2. Other fractures
3. Orthopedic surgery
4. Blunt trauma to fatty organs (liver)
5. Liposuction
6. Bone marrow biopsy
Causes of fat embolism syndrome in nontraumatic circumstances
1. Pancreatitis
2. DM
3. Lipid infusion
4. Sickle Cell Crisis
5. Burns
6. Osteomyelitis
7. Alcoholic fatty liver
8. fatty liver of pregnancy
9. Cardiopulmonary bypass
Classic Triad of Fat Embolism Syndrome (FES):
Clinical diagnosis that can be made when the classic triad of hypoxemia, neurological
abnormalities, and the petechial rash are present in the appropriate clinical setting (for example
long bone fracture)
Diagnostics:
CXR: air space disease due to edema or alveolar hemorrhage
CT of Chest: lung with ground glass opacities or nodules
MRI of head: starfield pattern of diffuse, punctate and hyperintense lesions
CBC: may show anemia, thrombocytopenia, and coagulation abnormalities like DIC
CTA of Chest is not usually done
Treatment Fat Embolism
No definitive treatments: treat the cause.
Similar to the patient with ARDS: oxygen, BiPAP, and mechanical ventilation
RBC exchange transfusion in sickle cell disease (monitor for acute chest syndrome and
multiorgan failure syndrome)
Fluid resuscitation
Rarely: ICP monitoring due to massive cerebral involvement, IV vasopressors,
mechanical/cardiac support devices (ECMO for refractory shock)