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.