A 17-year-old male sustained right midshaft tibia and fibula fractures in a high school football game. The patient had previously been healthy without significant past medical history. The patient was transported to a local hospital where radiographs demonstrated a short oblique fracture of the tibial diaphysis with mild comminution (AO/OTA classification 42-B2) (Figure 1). At the outside emergency department, the patient was placed in a long leg splint and discharged home with planned definitive fixation the following morning.
Following discharge, the patient experienced a syncopal episode at home and returned to his local emergency department. On arrival, he was found to be hypoxic, requiring 1-3 L/min of low flow nasal cannula (LFNC) oxygen to maintain saturation. A chest radiograph demonstrated mild bilateral interstitial and alveolar opacities (Figure 2). CT of the chest was notable for scattered ground-glass opacities. The patient tested negative for COVID-19. Given the patient's fracture history, respiratory symptoms, and chest imaging, the pulmonology department at this hospital recommended the patient be transferred for a higher level of care for suspected FES.
The patient was admitted to the pediatrics service at our level I pediatric trauma center at approximately 2000, 24 hours postinjury. He was febrile to 38.0 C and requiring 3 L/min LFNC to maintain saturations. Otherwise, vital signs were within normal limits. The patient was at his baseline mental status. The orthopaedic surgery service was first notified about the patient once he had arrived in the hospital, and the orthopaedic resident on-call was present at the bedside at approximately 2100. On exam, the patient was now requiring 10 L/min via simple mask to maintain oxygen saturation in the mid-90s. Examination of the right lower extremity demonstrated diffuse swelling about the lower leg without concern for open fracture or compartment syndrome. The patient's splint wrapping was taken down and re-wrapped during the examination, but the splint was not removed.
A rapid response was called one hour after orthopaedic examination due to deteriorating respiratory status and new mental status changes. The patient was transferred to the pediatric intensive care unit (PICU) in acute hypoxic respiratory failure requiring continuous positive airway pressure (CPAP) at 50% FiO2 to maintain saturations. Repeat chest radiograph demonstrated worsening interstitial opacities (Figure 2). The orthopaedic service was not notified about the patient's transfer to the PICU and found out the patient had been transferred when the resident on-call presented to the patient's original hospital room in order to reassess the patient.
After discussion with the PICU team, who forecasted that the patient was likely to be intubated regardless of whether or not emergent operative intervention was pursued, the decision was made to provisionally stabilize the patient's fracture in an attempt to prevent further fat embolization. The patient was taken to the operating room emergently approximately 6 hours after arrival to our hospital and 3 hours after mental status changes and respiratory distress.
After the patient had been intubated on his hospital bed, he was carefully transferred to the operating table with his splint in place. With attention to minimize movement at the fracture site, the right lower extremity splint wrappings were removed with scissors. The anterior tibia was prepped with chlorhexidine and draped while keeping the splint in place and without manipulating the leg. A uniplanar external fixator was then applied with fluoroscopic guidance (Figures 3 and 4).
Following surgery, the patient was transferred to the PICU intubated. He was extubated approximately 12 hours postoperatively. His mental status had returned to baseline at the time of extubation. He was weaned from supplemental oxygen by the evening of postoperative day 3. He underwent intramedullary nailing using a reamer/irrigator/aspirator graft harvesting system (RIA 2, Synthes, West Chester, PA) to minimize fat embolization during definitive fixation on the afternoon of postoperative day 4. He was discharged from the hospital in good health on postoperative day 5. Three months postoperatively, the patient had returned to full activity and was without complaint. Three-month postoperative radiographs demonstrated fracture union (Figure 5).