Answer

Femoral diaphysis fracture with fat embolism

As with pelvic fractures a significant force is required to fracture the femoral diaphysis - it is the strongest bone in the body. The femoral shaft has a rich blood supply and femoral fractures are often associated with considerable blood loss and haematoma formation.

Fat embolism

Fat embolism is usually associated with long bone or pelvic trauma, but can rarely be associated with parenteral lipid infusion or corticosteroid treatment. The traditional explanation is that fat droplets from the bone marrow escape into the venous system and pass to the lung (and the brain via arteriovenous shunts). A second explanation is that altered internal homeostasis in the severely traumatised patient causes systemic release of fatty acids and chylomicrons which subsequently coalesce to give fat embolisation. Fat embolisation is a clinical diagnosis. Clinical features include hypoxia, tachycardia and fever. Red/brown petechial spots may appear over the trunk and axillae and if present are virtually diagnostic. Retinal, subconjunctival and oral haemorrhages are also sometimes seen.

The chest X-ray shows bilateral diffuse pulmonary infiltrates which appear 24-48 hours following the clinical picture. The CT head appearance may be normal but can show white matter petechial haemorrhages or changes consistent with microvascular injury.

Treatment is supportive. 157

Complications of femoral fractures

■ Haemorrhagic shock

■ Vascular injury

■ Neurological injury

■ Infection (with open fractures)

■ Respiratory complications

• Adult respiratory distress syndrome

■ DVT and pulmonary embolism

■ Complications related to the fracture: shortening, malrotation, non/delayed union.

Compartment syndrome

Compartment syndrome (or Volkmann contracture) occurs when perfusion pressure falls below tissue pressure in a fixed volume body compartment. The condition is most frequently associated with long bone fracture (Fig. 3.38) particularly of the tibia but has also been described in several other body compartments including femur, upper limb, abdomen and buttock. High energy trauma, long bone fractures, crush or penetrating injury, burns and vascular injury are all predisposing factors. When tissue pressure rises above perfusion pressure, capillary filling is impaired and tissue ischaemia results. Clinical symptoms include severe pain and burning. Sensory loss followed by motor nerve dysfunction may be present on clinical examination.

Measurement of compartment pressure should be undertaken if compartment syndrome is considered. Debate exists regarding the threshold pressure at which to perform fasciotomy but above 30mmHg is recommended by many. Early fasciotomy (within 6 hours) following the onset of compartment syndrome can be limb saving. If fasciotomy is delayed, permanent nerve damage, loss of limb and death can result.

■ How does the classification of hip fractures related to healing?

■ What are the main causes of morbidity and mortality following hip fracture?

Fig. 3.39 Quiz case.

■ How does the classification of hip fractures related to healing?

■ What are the main causes of morbidity and mortality following hip fracture?

Fig. 3.39 Quiz case.

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