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Fat Embolism Syndrome – Three Case Reports and Review of the Literature

Received: June 15, 2017
Revised: August 31, 2017
Accepted: September 7, 2017
J Trauma Inj 2017;30(3):107-111
Correspondence to
Leonidas Grigorakos, M.D., Ph.D.
Faculty of Nursing, Natio nal and Kapodistri-
an University of Athens, 2 Nikis Str., Kifissia,
Athens 14561, Greece
Tel: +30-210-3709522
Fax: +30 -210-3709520
eISSN 2287-1683
pISSN 1738-8767
Copyright © 2017 The Korean Society of Trauma
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Fat Embolism Syndrome – Three Case
Reports and Review of the Literature
Leonidas Grigorakos, M.D., Ph.D.1,2, Ioannis Nikolopoulos, M.D.3,
Stamatina Stratouli, M.D.2, Anastasia Alexopoulou, M.D.2, Eleftherios Nikolaidis, M.D.2,
Elef therios Fotiou, M.D.2, Daria Lazarescu, Ph.D.2, Ioannis Alamanos, M.D.2
1Faculty of Nursing, National and Kapodistrian University of Athens, Athens, Greece
2Intensive Care at Trauma, Hospital of Athens, KAT, Kissia, Athens, Greece
3Center of Respiratory Insufciency, Sotiria Chest Hospital, Athens, Greece
The fat embolism syndrome (FES) represents a condition, usually with traumatic
etiology, which may pose challenges to diagnosis while its treatment usually requires
supportive measures in the intensive care units (ICUs). The clinical criteria, including
respiratory and cerebral dysfunction and a petechial rash, along with imaging studies
help in diagnosis. Here we present three case reports of young male who developed
FES and were admitted to our ICUs after long bones fractures emerging after vehi-
cle crashes and we briey review FES literature. All patients' treatment was directed
towards: 1) the restoration of circulating volume with fresh blood and/or plasma; 2)
the correction of acidosis; and 3) immobilization of the affected part. All patients re-
covered and were released to the orthopedic wards. The incidence of cases of patients
with FES admitted in our ICUs records a signicant decrease. This may be explained
in terms effective infrastructure reforms in Greece which brought about signicant
improvement in early prevention and management.
Keywords: Embolism, Fat; Intensive Care Units; Long bone fractures; Fat embolism
prevention; Fat embolism management
Since it was rst described, more than 150 years ago, the fat embolism syndrome (FES)
has been considered a diagnostic enigma, which still poses challenges to diagnosis. This
difculty is based on the fact that it can complicate an array of clinical presentation
with a variable severity of illness. Although simple fat embolism may be a pathologic
nding with little clinical signicance, patients with FES have fat emboli in multiple
organs, which show extensive damage from this embolization [1]. While most patients
Journal of Trauma and Injury Volume 30, Number 3, September 2017
with FES fully recover, there is still an estimated 5 to 20%
mortality risk [2] while care is generally supportive.
We report three cases of young males with FES in the
setting of traumatic long bones fractures. Although rare,
FES is more common at level I trauma centers, where
polytrauma patients are often transferred for specialized
care. Early diagnosis, high-pressure positive end-expira-
tory pressure, and supportive treatment are the mainstays
of treatment [3]. Major and minor diagnostic criteria
for FES were proposed by Gurd and Wilson (Table 1).
Using their system, a diagnosis of FES could be made if
one major feature, four minor features, and fat macro-
globulinemia were present [4] Schonfeld proposed the fat
embolism index to aid in diagnosing FES (Table 2) [5].
A cumulative score of five or more over the first three
days of hospitalization corresponds with a diagnosis of
FES. However, given the complex nature of polytrauma
patients, it is often difcult to accurately diagnose FES as
these patients have multiple injuries and are often intu-
bated upon arrival. Here, we present three case reports of
young male who developed FES after long bones fractures
emerging after vehicle crashes.
We present the cases of three patients who were admitted
to our intensive care units (ICUs) three to ve days upon
their previous admissions to orthopedic clinics after ve-
hicle crashes. Their duration of stay before release to the
orthopedic clinics ranges from 5 to 17 days (mean average
10 days). All patients were male and their age ranged from
twenty to twenty-four years. All cases followed multiple
fractures with one or more long bones involved (Table 3).
In all cases there was a latent period between injury and
the onset of symptoms with an average time of seven-
ty-two hours after surgery for remanipulation of fractures.
No significant correlation was found between the time
of onset and the severity of the subsequent course. There
was marked variation in the clinical presentation (Table 4).
In one case the earliest recorded symptoms were cerebral,
usually drowsiness or confusion. In two cases unexplained
tachycardia and pyrexia heralded more specific signs.
However, respiratory dysfunction was observed rst in all
patients with dyspnoea, tachypnoea and/or haemoptysis.
One patient was intubated in the emergency department
due to respiratory insufficiency - shunt FiO2 100%, Sat
O2 78-82%, tachypnea up to 40 breaths/min, tachycardia
120-140 beats/min. Before intubation the patient main-
Table 1. Gurd and Wilson’s major and minor criteria for fat
Major features Minor features
Petechial rash Tachycardia
Respirator y symptoms plus bilat-
eral signs with positive radio-
graphic changes
Cerebral signs unrelated to head
Retinal fat or petechiae
Urinary fat globules or oligoanuria
Sudden drop in Hg-level
Sudden thrombocytopenia
High erythrocyte sedimentation
Fat globules in sputum
Tab le 2 . Schonfeld’s fat embolism index (FEI) score
Feature Pointsa
Diffuse petechiae 5
Alveolar infiltrates 4
Hypoxemia (<70 mm Hg) 3
Confusion 1
Fe ver >381
Heart rate >120 beats/min 1
Respiratory rate >30/min 1
aFive or more points are needed to diagnose FES. FES: embolism syn-
Tab le 3 . Nature of the injury
Patient 1 Patient 2 Patient 3
Segmental right femur
Lef t femur
Right femur
Fracture of right femur lef t
Extra ar ticular wirst fracture
Mandibule fracture
Open rupturing trauma of
chin and lower lip
Leonidas Grigorakos, et al. Fat Embolism Syndrome
tained good level of communication. Petechial rash was a
presenting sign in all our cases.
Upon admission in our ICUs, respiratory involvement
was predominant in all three patients. Two of them pre-
sented hypoxemia, diffuse pulmonary inltrates, mainly
median type, of middle and low pulmonary areas, bi-
lateral ground glass. One patient presented hypocapnia,
dyspnoea, tachypnoea and respiratory failure. Cyanosis
was uncommon even when arterial hypoxia was marked,
presumably because of concomitant anaemia. The arterial
oxygen tension was monitored in two cases and the mini-
mum PO2 level recorded ranged from 51 to 80.
All patients had radiographic examination of the chest
and the lms showed typical bilateral diffuse patchy areas
of consolidation (Fig. 1). In one case veins’ triplex was
performed and it revealed pathological ndings (bilateral
ne non-muscular sprains of pulmonary bases). In other
case, chest computed tomography (CT) showed a bilateral
ground-glass image while limb and cardiac ultrasound ex-
amination did not reveal any pathological ndings. There
was mild cerebral involvement in one patient associated
with head injury. One patient was fully orientated on ad-
mission, while the other two became confused. Petechial
rash were observed in all patients.
Pyrexia of 38.5 degrees Celsius or above and tachycar-
dia of 120 per minute or more were noted in two cases.
Ophthalmoscopy was recorded in two patients and was
normal. Some renal involvement was manifested in two
patients, as they became oliguric. Daily haemoglobin es-
timations were recorded and a drop of more than 25%
was found in all patients. Daily platelet counts were also
monitored with a recorded drop of 50% in only one pa-
tient. The erythrocyte sedimentation rate was raised, with
values of 30 to 50 mm. Fat globules larger than 8 microns
were found circulating in all cases, which resulted in me-
chanical obstruction of lung capillaries. The amount of
circulating fat did not appear to correlate with the clinical
severity of the condition. Fat globules were also found in
the urine on all three cases.
In all cases, treatment was directed towards: 1) the
restoration of circulating volume with fresh blood and/
or plasma; 2) the correction of acidosis; and 3) immo-
bilization of the affected part. Additional treatment was
primarily concerned with respiratory support. All patients
required full respiratory care with assisted ventilation and
oxygen while one patient who remained under suppres-
sion and analgesia for 7 days received all the routine care
of the unconscious patient with Pentothal, Remifentanil
Tab le 4 . Patients’ recorded symptoms and complications
Patient 1 Patient 2 Patient 3
Drowsiness and confusion Confusion Fully orientated
Tacycardia and pyrexia - Tachycardia and pyrexia
Respiratory dysfunction (dyspnoea, tachypnoea,
Respiratory dysfunction (dyspnoea, tachypnoea,
Respiratory dysfunction (dyspnoea, tachypnoea,
Petechial rash Petechial rash Petechial rash
Lung typical bilateral dif fuse patchy areas of
Lung typical bilateral diffuse patchy areas of con-
Lung typical bilateral diffuse patchy areas of con-
Hypocapnia and respiratory failure Hypoxemia Hypoxemia
Intubation - -
Pathological CT findings suggesting mild cere-
bral involvement (bilateral grand glass image)
- -
Fat globules >8 microns present, resulting in
result in mechanical obstruction of lung capil-
Fat globules >8 microns present, resulting in result
in mechanical obstruction of lung capillaries
Fat globules >8 microns present, resulting in
result in mechanical obstruction of lung capil-
Fat globules in the urine Fat globules in the urine Fat globules in the urine
Oliguria Oliguria -
CT: computed tomography.
Journal of Trauma and Injury Volume 30, Number 3, September 2017
and Midazolam.
One patient was transfused with red blood cells and
fresh frozen plasma due to low hematocrit. Antibiotics
were given to two patients with moderate or severe lung
involvement. Esmolol was required in one case with un-
controllable tachycardia. Two patients were given Lasix
or Furosemide for diuresis while one patient was given
hydrocortisone sodium succinate. All patients recovered
and were released to the orthopedic wards.
FES, which was rst described by Zenker in 1861, is com-
monly associated with long bone fractures and frequently
presents a constellation of neurological, pulmonary,
dermatological, and hematological symptoms. Actually,
cerebral complications are considered to be the most se-
vere complications of fat embolism [5]. In our case, the
petechial rash was a presenting sign in all our cases which
proved to be determinant factor for early diagnosis of
Since its rst description, two main theories were pro-
posed to explain the origin of FES: the mechanical and
biochemical theories. The former states that three condi-
tions are necessary for the development of fat embolism:
injury to adipose tissue, rupture of veins within the zone
of injury, and a mechanism that causes the passage of
free fat into the open ends of blood vessels. The latter
theory argues that plasma mediators mobilize fat from
body stores and cause the coalescence of larger droplets.
The presence of fat within various tissues (i.e., lungs and
brain) initiates an inflammatory cascade causing injury
[6]. However, these mechanisms are not necessarily mu-
tually exclusive The former presumes that fractures of
marrow containing bone have the highest incidence of
FES due to disrupted venules in the marrow which are
tethered open by osteous attachments that allows easy
entry of marrow contents into the circulation [7]. From
there on, it can enter the arterial circulation via a patent
foramen ovale (PFO) causing increases in pulmonary
artery and right heart pressures or by micro embolism
via the lung demonstrated even in the absence of a PFO;
the latter could explain the neurologic disease and pe-
techiae associated with FES [8]. The biochemical theory
or mechanism explains that destabilization of a plasma
chylomicronemulsion lead stocoalescence off at stores.
Subsequently, degradation of embolized fat into toxic
intermediaries (free fatty acids and Creactive protein) re-
sults in the development of FES [9].
The incidence of FES ranges from <1 to 29% and it
varies considerably according to the cause. The actual in-
cidence of FES is not known, as mild cases often go unno-
ticed. In patients with long bone fractures FES incidence
has been reported to occur in 0.5 to 11% [10]. However, it
is seen more frequently in closed fractures than open frac-
tures and risk increases in proportion with the number of
bone structures involved [11].
The early fixation of long-bone fracture (early immo-
bilization of fractures and operative correction rather
than conservative management) is important to prevent
or to decrease the severity of FES. One report estimates
a 70% reduction in pulmonary complications from this
intervention alone [12]. Further, two surgical techniques
are debated as possible means of preventing fat embolism
syndrome. However, these two techniques are considered
but not used routinely by surgeons. The rst is “venting,”
Fig . 1. Patient 2 - chest X-ray.
Leonidas Grigorakos, et al. Fat Embolism Syndrome
in which a hole is made distal to the site of intramedul-
lary nail placement. This reduces intramedullary pressure
elevation and, therefore, extravasation of fat into the
circulation. The second technique is the use of a reamer,
irrigator, aspirator (RIA) device. Reaming before intra-
medullary nail placement can release fat deposits into the
circulation. The RIA device irrigates and aspirates resident
fat deposits as it reams the canal, releasing fewer deposits
into the circulation.
Preoperative use of methylprednisolone may prevent
the occurrence of FES [13]. The use of corticosteroid
prophylaxis is controversial and few studies have shown
decrease in the incidence and severity of FES. However,
the administration to one of the three patients of hydro-
cortisone sodium succinate (125 gr/6 h for three days)
proved to be effective for his treatment. Smaller-diameter
nails and unreamed nailing have been mentioned as being
useful in the prevention of FES. Both in polytraumatism
patients and in those being submitted to surgery, it is cru-
cial to avoid hypovolemia and hypoxia, because these are
factors that much worsen a FES prognosis. Thus, in both
situations, the close monitoring of the blood pressure and
the PaO2 is recommended, as well as correcting their de-
viations as soon as they are detected.
To conclude, we have to stress out that during the last
years, in Greece, we record a serious decrease not only in
mortality rates of patients with FES but also in the cases of
patients with FES admitted in our ICUs, when compared
to the same units 15-20 years ago [14]. This may be ex-
plained in terms of infrastructure reforms which induced:
1) a signicant reduction of road accidents, 2) the mod-
ernization of National Emergency Center which led to a
more rapid treatment of injuries, and 3) an increase in
the number of ICU beds and surgical treatment [15]. All
these developments brought about more effective early
prevention and management of patients in the emergency
departments and in the orthopedic clinics. However, in
order to strengthen such a statement future research is
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... However, incidence rates of FES ranging from <1% to 29% have been reported. 4,5 The two main theories for the formation of fat embolism are the mechanical theory, which emphasizes vascular obstruction, and the biochemical theory, which emphasizes the inflammatory response that results from the trauma and leads to the development of embolized fat tissue. 6 Multiorgan dysfunction may occur, causing FES and presenting as a clinical triad of hypoxia, change of consciousness, and petechiae. ...
... 7 A change in consciousness occurs in up to 86% of patients with manifestations ranging from headache to coma. 4,5,8 Two cases of early-onset FES have been reported at 3 hours and <12 hours post-injury, respectively. [9][10][11] Although the neurological deficit is thought to be transient and reversible in most cases, the condition may be complicated by misdiagnosis or delayed diagnosis. ...
... 18,19 The fat embolism index score proposed by Schonfeld is also helpful and is based on seven clinical signs; a positive diagnosis of FES is suggested if a cumulative score of !5 is achieved during the first 3 days of hospitalization. 4,20 Patients with isolated cerebral fat embolism have no respiratory dysfunction but exhibit a change of consciousness, which is usually accompanied by new-onset neurological deficit, apathy, convulsion, hallucination, facial palsy, or hemiplegia. Although the patient in the current case did not initially meet Gurd and Wilson's criteria 17 (only one major and three minor criteria were met: cerebral symptoms in a patient with non-head injury, tachycardia, renal changes, and drop in hemoglobin), cerebral fat embolism was strongly considered because the patient presented with sudden unresponsiveness, dullness, and muteness with quadriplegia 10 days after fixation of the left tibial plateau fracture. ...
Full-text available
Fat embolism syndrome (FES) is a complication of long bone fractures that often occurs within 72 hours of injury. Early-onset isolated cerebral fat embolism is catastrophic and rarely reported. We herein present a rare case of delayed-onset isolated cerebral FES that developed 10 days after definite fixation of a left tibial plateau fracture. A 70-year-old woman was injured in a traffic accident and diagnosed with a left tibial plateau fracture. However, she developed sudden loss of consciousness (E4V1M1) and quadriplegia 10 days after fracture fixation. Her vital signs showed no respiratory distress. Diagnosis of isolated cerebral FES was made based on magnetic resonance imaging of the brain, the findings of which were compatible with the clinical neurological findings. After supportive care and rehabilitation, her consciousness became clear on the second day of admission, and her consciousness changed to E4V5M6. She gradually regained strength in her right limbs but had residual left limb paraplegia. Isolated cerebral FES should always be considered for patients who develop a change in consciousness, even beyond 72 hours after injury. Imaging may not initially show definitive abnormalities. Repeated magnetic resonance imaging should be considered if the initial clinical presentation does not fully meet Gurd's criteria.
... En las tablas se describen los criterios diagnósticos para cada autor y los encontrados en nuestro paciente. Actualmente no existe un tratamiento específico para el SEG, la actuación médica debe enfocarse a su prevención, que se basa en la corrección rápida del shock inicial, la estabilización y fijación de las fracturas de huesos largos en el trauma múltiple dentro de las primeras 24 horas (9)(11),realizando esta intervención Grigorakos et al menciona una reducción del 70% en las complicaciones pulmonares (14). Además la literatura recomienda priorizar la fijación externa sobre la intramedular en los casos que se pueda (15). ...
... The ecuador journal of medicine The ecuador journal of medicine 71 de casos se evidenció que la administración de succinato sódico de hidrocortisona (125 gr / 6 h durante tres días) demostró ser eficaz para su tratamiento. (14) El uso preoperatorio de metilprednisolona puede prevenir la aparición del síndrome de embolia pulmonar (9)(16) pero requieren estudios prospectivos que validen sus resultados antes de aceptarlos como práctica rutinaria. ...
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Introducción: El síndrome de embolia grasa es una complicación infrecuente potencialmente fulminante que se observa en pacientes politraumatizados . La presencia de glóbulos de grasa en la circulación pulmonar, da como resultado un cuadro rápidamente progresivo, que puede llevar a la pérdida del conocimiento o insuficiencia respiratoria aguda, incluso al síndrome de dificultad respiratoria del adulto (SDRA). En la radiografía pulmonar se aprecia un patrón difuso similar a la nieve, como resultado del edema pulmonar intersticial típico. El tratamiento es principalmente de soporte. Presentación del caso: Describimos un caso infrecuente de un paciente masculino de 24 años, sin antecedentes médicos, que fue intervenido en 2 ocasiones con fijación interna y colocación de clavo intramedular en peroné y tibia derecha respectivamente, 26 horas posteriores a la primera intervención presenta hipoxemia severa, sin afectación neurológica, e ingresó a nuestra unidad de cuidados intensivos (UCI), se descartó tromboembolia pulmonar, etiología infecciosa y cardiogénica , la tomografía y radiografía de tórax evidenció : infiltrados difusos bilaterales compatible con embolia grasa. Se dio tratamiento de soporte con adecuada resolución. Conclusiones: El síndrome de dificultad respiratoria del adulto (SDRA) por embolia grasa constituye un desafío diagnóstico, el reconocimiento rápido es importante para que la terapia de apoyo pueda instituirse tempranamente.
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Background Many studies have established intravenous corticosteroid as an effective prophylactic therapy in fat embolism syndrome (FES). However, its use is limited among surgeons because of systemic side effects. Inhalational steroids have least systemic effects and are widely used for several chest conditions (i.e., asthma), but their effectiveness in FES has not been established. Question/purposeThis study was sought to evaluate the (1) efficacy and (2) safety of inhalational Ciclesonide (CIC) in prevention of FES and treatment of hypoxemia in isolated skeletal trauma victims. MethodsA nonrandomized prospective control trial was designed in which all patients between 18 and 40 years with isolated skeletal injury who presented within 8 h of injury were allocated to either Trial group or control group. Trial group patients received 640 mcg of inhalational CIC with a metered-dose inhaler at the time of admission, and at 24 h. Control group patients did not receive any prophylactic therapy. Both groups were evaluated for development of FES (Gurd’s criteria) and hypoxemia (PaO2 <70 mmHg) for 72 h. The complications related to CIC administration were evaluated in trial group patients during their hospital stay. ResultsOf 35 patients in each group, two patients in Trial group and nine patients in control group developed FES (P = 0.022). Eight patients in Trial group had hypoxemia at the time of admission, six of them improved and one additional patient developed hypoxemia after inhalational CIC administration. In control group, ten patients had hypoxia at the time of admission, only one of them improved and remaining nine patients had persistent hypoxemia even after 72 h. Additionally, three patients developed hypoxemia. A significant improvement in hypoxemia and a significant decrease in the incidence of FES were observed in Trial group (P < 0.05) compared to control group. None of the patients presented with any complications or adverse effects of steroid in Trial group. Conclusion Inhalational CIC is a safe and effective therapy for prevention of FES and also an effective drug for treatment of hypoxemia in orthopedic trauma victims. Level of evidence Level III, therapeutic study.
The concept of early surgical stabilization of long-bone fractures in patients with multiple injuries became firmly established in the 1970s and 1980s. During the 1990s questions were raised about the early total cafe of all long-bone fractures in these patients. In particular, it was pointed out that patients with severe chest injuries and those with severe head injuries require special consideration. Although patients in those circumstances do require careful attention, most of the literature suggests that continued early surgical stabilization of these fractures, in particular femoral neck fractures, is important for patients who suffer polytrauma. The concept of early temporary surgical stabilization (damage control orthopedic surgery) has recently been suggested. In the majority of cases, femoral shaft fractures can be treated with interlocked intramedullary nailing.
During the period 1988-1993, twenty three (23) patients (18 males and 5 females with a mean age 37.2 years), who had sustained multiple injuries and were reported to have Fat Embolism Syndrome (FAT), were treated in our Intensive Care Unit (ICU). Here, we describe, retrospectively, our experience with these cases. In all patients the diagnosis was documented by Guard's criteria: a) Major: petechial rash 7 (30.4%), respiratory symptoms 23 (100%), cerebral signs 5 (21.7%), b) Minor: tachycardia 23 (100%), pyrexia 18 (78.2%), retinal changes 7 (30.4%) and c) Laboratory: low haematocrit 23 (100%), fat in sputum 16 (69.5%), fat macroglobulinaemia 14 (60.8%). All patients needed volume replacement, they were given high doses of steroids and received supplemental oxygen by Venturi/Mask. 8 patients (34.7%) developed full Adult Respiratory Distress Syndrome (ARDS) and were put on Mechanical Ventilation and 2 of them died. The mean duration of stay in the ICU was 15 ± 12 days and the mean duration of Mechanical Ventilation was 18 ± 10 days. We support the diagnostic value of Guard's criteria, the beneficial effects of adequate circulating volume and the steroid therapy as well as the reduction of the severity of FES when oxygen is administrated as soon as possible and avoidance of hypoxaemia is obtained.
Since the discovery of free neutral fat in the blood vessels following injury, the subject of fat embolism has been widely investigated clinically and experimentally. As may so easily happen when an apparently direct and unequivocal cause-effect relationship is presented, the search for other causes has been overlooked; and this, in spite of the fact that the more familiar we become with fat embolism, the less unequivocal the commonly accepted etiology appears. This article is the record of an attack on this unsettled problem from a new direction.A detailed review of the literature of fat embolism need not be given here. It has been thoroughly covered in English by Warthin (19131) and in German by Landois (19232), Paul and Windholz (19253) and others.We need only summarize those facts on which complete agreement exists among most authors, and in somewhat more detail discuss those observations that
The importance of fat embolism as a complication of bony trauma has been recognized for over 100 years. During this time there have been short bursts of rapid progress in knowledge and understanding of the problem separated by periods of confusion and misunderstandings. Presently, as a result of improvements in technology, new information has been derived to reduce significantly the morbidity and mortality of fat embolism.
The importance of fat embolism as a complication of bony trauma has been recognized for over 100 years. During this time there have been short bursts of rapid progress in knowledge and understanding of the problem separated by periods of confusion and misunderstandings. Presently, as a result of improvements in technology, new information has been derived to reduce significantly the morbidity and mortality of fat embolism.
1. A diagnostic procedure is described which is specific for fat embolism. It allows identification of the pathological fat globules On a stained slide. 2. The amount of pathological fat can be estimated by comparing the serum triglyceride levels before and after filtration. 3. The method is simple, reproducible and inexpensive.