Intended for healthcare professionals

Rapid response to:

Endgames Case Review

A man with a traumatic lower limb injury

BMJ 2019; 367 doi: https://doi.org/10.1136/bmj.l6246 (Published 28 November 2019) Cite this as: BMJ 2019;367:l6246

Rapid Response:

You don't look for it if you don't think about it.

Dear Editors

I thank the authors for their attempt at educating other non-orthopaedic colleagues on the management of a trauma patient with an open tibial-fibular fracture.

I certainly hope that, despite the glaring omission from the description, possibly due to word limit rules, the patient had adequate trauma call assessment, including a tertiary survey at the emergency department interface.

Also similarly that the patient had undergone washout and debridement of the wound and exposed bone and possibly primary closure of traumatic wound prior surgical fixation of fracture with an intramedullary device. The use of negative pressure dressing in wound management of open fractures is still in my opinion a highly controversial matter (ref 1).

I am however seriously disturbed by the absence of "fat embolism syndrome" (FES) in the list of potential complications of fractures as provided by the authors.

Not only is FES highly relevant in the perioperative management of long bone fracture, it is also very important in decision making and surgical techniques of insertion of intramedullary nails (IMNs).

The criteria of FES is well described (ref 2) but the frequency of FES in long bone fractures is wildly variable. Some studies (usually retrospective) reported 1-2% rate of FES found in long bone fractures, whereas other authors (possibly in trauma centre with research protocol in place) identifies FES occurring about 20-30%. What is certainly known is that FES can be subclinical and missed when not specifically/routinely looked for during formal trauma assessment.

This has real medico-legal implications particularly when adult long bone fracture are preferentially managed with reamed intramedullary fixation (15% had FES postoperatively), as preoperative FES may either be mistaken as operative complication if only recognised post-operatively or worse a pre-existing FES may be worsen by reaming and insertion of IMNs.

The awareness of pre-operative FES may result in modified IMN insertion technqiues (without reaming reducing FES rate to 7%), open reduction internal fixation with plating, or external fixation with frames.

The authors and readers should approach all long bone fracture (closed or open injury) with a highindex of suspicioun for FES.

Reference
1. https://www.bmj.com/content/364/bmj.k4411/rapid-responses
2. Gurd AR, Wilson RI. The fat embolism syndrome. J Bone Joint Surg (Br) 1974;56B:408–416.

Competing interests: No competing interests

02 December 2019
Shyan Goh
Orthopaedic Surgeon
Sydney, Australia