Can a tibial fracture cause fat embolism?

From the Guidelines

Yes, a tibial fracture can cause fat embolism syndrome (FES). According to the most recent and highest quality study, long bone fractures, particularly those involving the tibia, femur, and pelvis, are among the most common causes of fat embolism 1. When a bone breaks, fat globules from the bone marrow can enter the bloodstream and travel to various organs, most critically the lungs, brain, and skin. This typically occurs within 24-72 hours after the injury. The classic triad of symptoms includes respiratory distress, neurological abnormalities, and petechial rash. The severity of the fracture, especially if it's comminuted (broken into multiple fragments), increases the risk of fat embolism.

Key Points to Consider

• Early fracture stabilization is crucial in preventing this complication, as immobilization of the fracture site can reduce the release of fat emboli 1.
• Patients with tibial fractures should be monitored closely for signs of respiratory distress, confusion, or rash in the days following injury, as prompt recognition and treatment of fat embolism syndrome can significantly improve outcomes.
• The incidence of fat embolism syndrome is low, but the embolization of marrow fat appears to be an almost inevitable consequence of long bone fractures 1.
• Treatment is primarily supportive, focusing on maintaining adequate oxygenation, hemodynamic stability, and addressing specific organ dysfunction.

Recommendations for Management

• In the absence of severe visceral injury, circulatory shock, or respiratory failure, an early definitive osteosynthesis of diaphyseal fractures is recommended within the first 24 hours to reduce the incidence of local and systemic complications 1.
• A temporary stabilisation (external fixator or osseous traction) may be necessary in some cases, followed by a delayed osteosynthesis surgery once the clinical status is stabilised 1.

From the Research

Fat Embolism Syndrome and Tibial Fractures

• A tibial fracture can cause fat embolism syndrome (FES), as evidenced by several studies 2, 3, 4, 5.
• The incidence of FES in patients with isolated tibial fractures has been reported to be around 19% 2.
• FES can occur in both displaced and nondisplaced tibial fractures, and even in patients who are deemed clinically stable 4, 5.
• Symptoms of FES include respiratory distress, mental status changes, and petechiae, and can be severe enough to require advanced life support, such as extracorporeal membrane oxygenation (ECMO) 6.
• Treatment of FES typically involves supportive care, including oxygen therapy and fluid management, and in some cases, surgical intervention, such as intramedullary nailing of the fracture 3, 4.
• The mortality rate for FES is generally low, but the syndrome can cause significant morbidity and prolong hospitalization 2.

Risk Factors and Diagnosis

• The risk of developing FES after a tibial fracture may be higher in certain patient populations, such as young adults and those with high-energy trauma 2, 3.
• A high index of suspicion is required to diagnose FES promptly and institute appropriate treatment, especially in patients who are at high risk or who present with respiratory distress or mental status changes 3, 4.
• The use of injury severity scoring systems may not always be reliable in predicting the risk of FES in patients with isolated long bone fractures, and other parameters, such as the patient's clinical stability and the presence of respiratory symptoms, should also be considered 4.