Fat Embolism and Damage Control Orthopaedics

A young  pedestrian was hit by a car and sustained Mid shaft of tibia fracture of her left leg. After 24 hours, he suffered from shortness of breath. Chest X-ray is shown as below. What may be the cause. 
Fat Embolism in Pulmonary Artery




Upright portable AP chest x-ray showing hypovolemia secondary to a pulmonary embolism, knowns as Westermark sign. Image courtesy
https://emergencymedicinecases.com/wp-content/uploads/2012/03/015-15-Figure-1.jpg

Radiographic other findings


PA chest xray in a patient with a PE. Arrow denotes the area of pulmonary infarction, known as Hampton hump. 
Image courtesy  http://www.imagingpathways.health.wa.gov.au/images/pe/ham.jpg

 Sometimes Atelectasis is found.
What is Damage Control Orthopaedics (DCO) ?
    
    Planned and staged surgical strategy in management of polytrauma patients to minimize effects of            second hit on already limited physiological response. 

     First Hit - from injury and body's response to this injury. 
     Second Hit - surgery

    Studies suggest that primary ex-fixator and secondary nailing improves outcome. It decreases                     incidence of MODS and ARDS.

How to decide which patient requires DCO and what are its alternative ?
      Alternative to DCO 
            -Early total care, early treatment of all fractures 
     DCO indications - 
                Injury Severity Scale (ISS)> 20
                Abdominal or pelvic trauma in hypovolaemic shock (SBP < 90 mmHg)
                Anyone with bilateral lung contusion

What is ISS ?
       Based on Abbreviated Injury Scale (AIS)
        Each body system gives on AIS of 1-6 with 6 most serious .
        ISS is Dervied from adding squares of 3 most severely injured body system.
        Score > 16 is considered injured. 

When to expect to operate on a DCO ?
        Made in conjunction with anaesthetist and intensivist.
        At least after four days.
        BP, HR, T  - Normal
        ABG- Corrected
        Convert Ex-fixator to a Nail in 10 days to avoid risk of fractures.

                 

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