OR2.11 | Femoral Shaft Fracture and Fat Embolism Recognition — Summary & Reflection

KEY TAKEAWAYS

Femoral shaft fractures are high-energy injuries associated with blood loss of 1–2 litres into the thigh, haemorrhagic shock, and a unique systemic complication — fat embolism syndrome. Clinical features include shortening, external rotation, thigh swelling, and inability to weight-bear; neurovascular examination is mandatory. ATLS resuscitation (IV access, fluids, Thomas splint) precedes definitive management. Plain radiographs of the full femur including hip and knee are the initial investigation. Definitive management is intramedullary nailing for adults and adolescents (standard of care), traction or skin splintage for neonates, and flexible nailing for children 5–11 years. Fat embolism syndrome presents 24–72 hours post-injury with the triad of respiratory failure, neurological changes, and petechial rash. Gurd criteria require ≥1 major criterion (petechiae, PaO₂ <60 mmHg, CNS depression, pulmonary oedema) plus ≥1 minor criterion. Management of FES is supportive: oxygen, lung-protective ventilation for ARDS, haemodynamic support; early fracture fixation is the best prophylaxis.

REFLECT

You have just performed an intramedullary nailing of a femoral shaft fracture in a 26-year-old man. He is extubated and transferred to the ward. At 6 AM, 30 hours post-operatively, the night nurse calls to say he is 'confused and not making sense', with SpO₂ of 91% on room air and temperature 38.4°C. When you arrive, you notice tiny reddish-brown spots scattered across his upper chest and the whites of his eyes. Consider: what is the most likely diagnosis, what is the single most important initial management step, and what aspect of his perioperative care (if any) could have reduced this risk? How would you distinguish this presentation from hospital-acquired pneumonia or pulmonary thromboembolism?