How can fat embolism be prevented in patients with fractures?

Prevention of Fat Embolism in Fractures

The most critical strategy to prevent fat embolism syndrome is early definitive fracture stabilization within 24 hours of injury in hemodynamically stable patients, particularly for femoral and tibial shaft fractures. 1

Risk Stratification: Determine Surgical Timing Based on Patient Stability

The prevention strategy hinges on identifying whether your patient can tolerate early definitive surgery or requires a damage control approach:

For Hemodynamically Stable Patients WITHOUT Severe Associated Injuries

Perform early definitive osteosynthesis within 24 hours to dramatically reduce fat embolism syndrome risk. 1

• This approach is particularly crucial for femoral and tibial shaft fractures, which carry the highest risk of respiratory complications and fat embolism syndrome. 1
• Early fixation (within 24 hours) reduces fat embolism syndrome incidence from 10.4% to 1.8% compared to delayed fixation. 2
• The mechanism: early stabilization prevents ongoing fat particle release from the fracture site and reduces the inflammatory "second hit" that occurs with delayed surgery. 1

For Unstable Patients WITH Severe Associated Injuries

Use damage control orthopedic surgery (DCO) with temporary stabilization if the patient has any of the following: 1

• Severe visceral injuries (brain, thorax, abdomen, pelvis, or spinal cord)
• Circulatory shock
• Respiratory failure
• Coagulopathy

Temporary stabilization options include: 1

• External fixation
• Skeletal traction

Then perform delayed definitive osteosynthesis once the patient is physiologically optimized (stable circulatory status, respiratory function, and coagulation). 1

Intraoperative Techniques to Minimize Fat Embolization

When performing intramedullary nailing or femoral surgery, employ these specific technical measures:

Canal Preparation

• Thoroughly wash and dry the femoral canal before any instrumentation using pressurized lavage to remove fat and marrow contents. 3
• This mechanical removal of intramedullary fat reduces the substrate available for embolization. 3

Avoid Excessive Pressurization

• Do not vigorously pressurize cement in high-risk patients. 3
• Insert cement in retrograde fashion on top of a plug using a cement gun. 3
• Remove suction catheters as soon as they become blocked with cement. 3

Anesthetic Management

• Ensure adequate hydration before and during anesthesia. 3
• Maintain systolic blood pressure within 20% of pre-induction values throughout the procedure. 3
• Increase inspired oxygen concentration during critical moments (canal reaming, nail insertion). 3

Postoperative Care

• Administer supplemental oxygen for at least 24 hours postoperatively. 3

Critical Pitfalls to Avoid

DO NOT Use Corticosteroids

Corticosteroids are explicitly contraindicated for fat embolism prevention or treatment. 4, 3

• High-dose corticosteroids increase mortality in traumatic brain injury patients. 4
• The Society of Critical Care Medicine and European Society of Intensive Care Medicine recommend against corticosteroid use in major trauma. 4
• This represents outdated practice that should be abandoned. 4

DO NOT Rush Unstable Patients to Definitive Surgery

• The surgical "second hit" from definitive osteosynthesis in physiologically unstable patients can trigger massive inflammatory mediator release, leading to multiple organ failure and worsening fat embolism syndrome. 1
• Management of intracranial hypertension takes precedence over fracture fixation. 4

Basic Preventive Measures

Immediate Fracture Immobilization

• Immobilize fractures as completely as possible at the scene and during transport to prevent ongoing fat particle release. 5
• Even with optimal early external fixation, fat embolism syndrome can still occur, though rarely. 6

Maintain High Index of Suspicion

• Monitor for the classic triad: respiratory manifestations, cerebral effects, and petechiae. 6
• Fat embolism syndrome occurs in 3-4% of patients with long bone fractures despite occurring in over 90% at a microscopic level. 7
• Suspect fat embolism syndrome when patients exhibit bizarre mental, pulmonary, or circulatory symptoms following fracture. 5