Rev. bras. ortop. vol.52 número5

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r e v b r a s o r t o p . 2017;52(5):535–537

SOCIEDADE BRASILEIRA DE ORTOPEDIA E TRAUMATOLOGIA

w w w . r b o . o r g . b r

Original

article

Fat

embolism

syndrome

in

femoral

shaft

fractures:

does

the

initial

treatment

make

a

difference?

夽

Jânio

José

Alves

Bezerra

Silva

∗

_,

_Diogo

_de

_Almeida

_Diana,

_Victor

_Eduardo

_Roman

_Salas,

Caio

Zamboni,

José

Soares

Hungria

Neto,

Ralph

Walter

Christian

IrmandadedaSantaCasadeMisericóridiadeSãoPaulo,SãoPaulo,SP,Brazil

a

r

t

i

c

l

e

i

n

f

o

Articlehistory:

Received29July2016 Accepted30August2016

Availableonline14September2017

Keywords:

Femoralfractures Fracturefixation Multipletrauma Fatembolism

a

b

s

t

r

a

c

t

Objective:Toidentifytheriskfactorscorrelatedwiththeinitialtreatmentperformed.

Methods:This isa retrospective study involvinga total of272patients diagnosed with femoralshaftfractures.Ofthepatients,14%werekeptatrestuntilthesurgicaltreatment, 52%underwentexternalfixation,10%receivedimmediatedefinitivetreatment,and23% remainedinskeletaltraction(23%)untildefinitivetreatment.

Results:Thereweresixcasesoffatembolismsyndrome(FES), whichshowedthat poly-traumaisthemainriskfactorforitsdevelopmentandthatinitialtherapywasnotimportant.

Conclusion: PolytraumapatientshaveagreaterchanceofdevelopingFESandtherewasno influencefromtheinitialtreatment.

Síndrome

da

embolia

gordurosa

na

fratura

diafisária

de

fêmur:

o

tratamento

provisório

faz

diferenc¸a?

Palavras-chave:

Fraturasdofêmur Fixac¸ãodefratura Traumatismomúltiplo Emboliagordurosa

r

e

s

u

m

o

Objetivo:Identificarosfatoresderiscoecorrelacioná-loscomotratamentoinicial.

Métodos:Estudo retrospectivo que envolveu 272 pacientes com diagnóstico de fratura diafisáriadefêmur;14%permaneceramemrepousoatéotratamentocirúrgico,52%foram submetidos afixac¸ãoexterna,10%fizeramotratamentodefinitivoimediatoe23% per-maneceramcomtrac¸ãoesqueléticaatéotratamentodefinitivo.

Resultados: Foramseiscasosdesíndromeda emboliagordurosa(SEG), nosquaisse evi-denciouqueopolitraumaéoprincipalfatorderiscoparaseudesenvolvimentoequeo tratamentoinicialinstituídonãooinfluenciou.

夽

PaperdevelopedatSantaCasadeSãoPaulo,DepartamentodeOrtopediaeTraumatologia,GrupodeCirurgiadoTrauma,SãoPaulo, SP,Brazil.

∗ _{Corresponding}_author_.

E-mail:janioalves@gmail.com(J.J.Silva). http://dx.doi.org/10.1016/j.rboe.2016.08.021

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rev bras ortop.2017;52(5):535–537

Conclusão: Pacientespolitraumatizadosapresentaramumamaiorchancededesenvolver SEGenãohouveinfluênciadotratamentoinicialinstituído.

Introduction

Thereleaseoffattyemboliintothebloodstreamcanleadto lesionanddysfunctionofoneormoreorgans,definedasfat embolismsyndrome(FES),mainlyduetothemobilityinthe focusofthefracture1_;_however, _despite_new_protocols _with

aggressivesupportandintensivetherapy,itremainsaconcern inshaftfracturesoflongbones.2–4_Thus,_early_skeletal

stabi-lizationissuggestedtopreventthissyndrome.1_However,_the

decisionontheapproachtobeuseddependsonthepatient’s clinicalpictureandavailabilityofresources.5

Thepresentstudyaimsatidentifyingtheriskfactorsfor fatembolism syndrome,and tocorrelateitwiththe initial treatmentestablished.

Casuistry

and

method

This is a retrospective observational study based on data frompatients’recordsfrom theDepartmentofOrthopedics andTraumatology, seen betweenJanuary2011and Decem-ber2015.Theinformationcollectedincludesepidemiological data,traumamechanism,fractureclassificationaccordingto theAOclassification,6_treatment_used,_and_clinical_outcome

regardingthepresenceorabsenceofFES.

Patientswithadiagnosisoffemoralshaftfractureofboth genders,withaminimumageof16yearswereincluded,and patientswithafractureinapathologicalbonewereexcluded. Two groupswere considered:polytraumatized and non-polytraumatized. The former group included those with multiplelesionsexceedingadefinedseverity(ISS≥17).6

Regarding the initial treatment, they were divided into: rest (patients who were kept resting in bed with cush-ions), transtibial skeletal traction; external fixation for damage control, and definitive surgical treatment, either withintramedullarynail or fixationwithplate andscrews. No patient was definitively treated with external fixation (Table1).

Table1–Distributionofpatientsastoinitialtreatment.

Initialtreatment n %

Rest 39 14.3

Externalfixation 144 52.9

Definitive 27 9.9

Skeletaltraction 62 22.8

n,numberofpatients.

Source:Dataobtainedfrommedicalrecordsstudied.SAME,ISCMSP andHEFR.

Ofthepatients,272patientswhosemedicalrecordswere reviewed met the inclusion criteria. There were 43 (16%) femalepatientsand229(84%)malepatients.Asfortheage group,theywerepredominantlybetween16and30years(63%) (Table2).FESwasevidencedinsixcases(2.2%).

Regardingthemechanismoftrauma,therewasa predom-inanceofvictimsofmotorcycleaccidents(57%),followedby caraccidents(17%),andfalls(14%).

WeusedtheAO6_group_{classification}_for_the_fractures_and

obtainedthefollowingdistributionaccordingtoFig.1. Forty-three patients were considered polytraumatized (ISS>17)(16%),and67(25%)hadcompoundfractures.

Results

Five out of229 male patients(2.2%) developedFES,and in thegroupof43femalepatientsweobservedonlyone(2.3%) (p=0.954).

TherewasaprevalenceofFESinadults,mainlybelow30 years(83.3%),butwithoutstatisticalsignificance(p=0.302).

Considering only the fact that the patient was poly-traumatized as a variable, out of 43, five (12%) developed FES, and in the non-polytraumatized group, only one did (p<0.001).

Sixpatients(4%)developedFES,fivewerepolytraumatized, ofthe144casesundergoingexternalfixationasinitial treat-ment.

Inthegroupof43polytraumatizedpatients,30underwent externalfixation,andofthesefive(17%)developedFES.Inthe remainderofthegroup(13patients),fourweresubmittedto bedrest,fourhaddefinitivetreatmentintheemergencyroom, fiveunderwentskeletaltraction,butnoneofthesecaseshad FES.

Regarding theAOclassification,6 _patients_with_FES_were

distributedbetween32-B2(50%),32-A2(33%)and32-A3(17%). WedidnotfindcasesofFESamongpatientswithfractures classifiedas32-C_.

Table2–Distributionofpatientsbyagegroup.

Agegroup n %

16–30years 172 63.2

31–40years 48 17.6

41–50years 19 7.0

51–60years 10 3.7

Over61years 23 8.5

n,numberofpatients.

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rev bras ortop.2017;52(5):535–537

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0.0% 6.6%

13.6% 34.9%

6.3% 18.4%

9.9%

2.6% _2.2% 5.5%

32-A1 32-A2 32-A3 32-B1 32-B2 32-B3 32-C1 32-C2 32-C3 5.0%

10.0% 15.0% 20.0% 25.0% 30.0% 35.0% 40.0%

Fig.1–DistributionofpatientsbyAOclassification.

Source_:_Data_from_medical_records_studied._SAME,_ISCMSP

andHEFR.

Discussion

FES is related to multiple factors, such as trauma energy, patient predisposition and initial resuscitation.1,7 _Pinney

etal.8_described_that_there_is_a_relation_of_FES_in_young_adult

patients,becausetheyareabletosurvivehighenergytraumas, whichfavorsthissyndrome.Ourstudyshowedthatamongthe sixpatientswithFES,fivewerelessthan30yearsold,butthis wasalsotheageatwhichthisfracturewasmoreprevalent, with172patients(63%).Thus,thereisapredominanceofFES inthegroupofyoungadults,butwithoutstatistical signifi-cance(p=0.302).Thesamewasobservedforthemalegender, inwhichfemoralshaftfractures weremorecommon (84%) andaccountfor83%ofpatientswithFES.

Theinitialmanagement ofapatientwith femoralshaft fracturedependsontheclinicalconditionsoftheirhospital admission,takinginto accountthe conceptsalready estab-lishedintheliteratureofEarlyTotalCareandDamageControl. In the patients submitted to definitive primary treatment, therewasnoFES,whichcorroboratesstudiesbyBoneetal.9

andLasanianosetal.7_They_demonstrated_that_the_early

fixa-tionoftheindividualfemoralshaftfractureinstablepatients maybebeneficial.

Inthegroupofpatientswithindicationoftemporary fixa-tion,Scannelletal.demonstratedthattherewasnodifference inclinicaloutcomesinpatientsundergoingbothexternal fix-ation(EF)and skeletal traction.10 _In_our_study,_there_was _a

higherprevalenceofFESinEFpatients(p<0.02),andnocases ofFESinthoseundergoingskeletaltraction,orbedrest. How-ever,amongthepatientsundergoingEF,in144(sixwithFES), 30werepolytraumatized(fivewithFES),whichwasconsidered themostimportantfactor(p=0.016).

Regarding the classification of fractures (classification AO6_),_which_takes_into_account_the_energy_of_the_trauma, _a

higherprevalenceoftypeCfractureswasexpectedinpatients withFESbecausetheyarefractures withgreater instability andgreatermobilityinthefocus;therefore,agreaterrelease offatemboli isexpected.1,6 _However,_in_our_study,_type_B2

fractures werethe mostprevalent intheFESpatientgroup (50%),butamongthese50patientswithfractureclassification AO32-B2,eightwerealsopolytraumatized(twowithFES),and 42 non-polytraumatized(one withFES).If wewere to mea-suretherelationshipbetweenembolismandpolytraumain this groupoffractures,therewasnostatisticalsignificance betweenthesevariables(p=0.098).

Conclusion

ThepolytraumatizedpatientismorelikelytodevelopFES,and inourcasuistrytheinitialtreatmentdidnotinfluenceinits development.

Conflicts

of

interest

Theauthorsdeclarenoconflictsofinterest.

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