Fractures (Open, Closed, Fat Embolus)

Definition/Etiology:

• Closed Fracture (Simple fracture) – break in the bone but the skin and surrounding tissue remain intact (CLOSED)
• Open Fracture (Compound fracture) – break in the bone but the skin and surround tissue are compromised (OPEN)
• Fat Embolism – characterized by systemic dissemination of fat emboli within the system circulation. Orthopedic trauma is the usual cause

Pathophysiology:

• Fracture – A break in the bone is usually caused by trauma/injury such as MVA, MCC, falls, etc.
• Fat embolus – Fat particles are released from the bone during the time of the fracture and enter the microcirculation, causing damage to the capillary beds.
  Usually, a fracture of the long bone or pelvis.

Route of the fat embolus:

• Lungs
• Brain
• Eyes

Clinical Presentation:

• Open fractures are at increased risk of neurovascular compromise, hemorrhage and INFECTION!
• Usually occur from high velocity injuries
• Skin will be open, extremity usually deformed
• Distracting injuries so don’t forget your ABCs, then address the fracture

Collaborative Management:

Fractures:

• X-ray (of course)
• CT may be helpful if it is a joint such as an ankle.
• CTA used to identify vascular injury if pulses are diminished
• Stabilize injury (splint/pillow/cast/etc)
• Check for distal pulses and sensation for baseline neurovascular status
• Hemodynamic monitoring
• Pain management
• Lifesaving tetanus
• Open fracture – Get those antibiotics on board.

Fat Embolus:

• Diagnosis based on hx of traumatic fx and symptoms
• Symptomatic treatment
• Good Oxygenation
• Albumin binds to fatty acids
• stabilization of the fracture

Evaluation | Patient Monitoring | Education:

Closed fracture? Splint it and forget it. (Rarely requires more than outpatient follow up and pain management)

• Watch for swelling (especially after splinting) due to risk for compartment syndrome

Open fracture? Hanging out for the night

• Ortho consult, surgical consult
• Open fractures may need reduced to take pressure off open area
• Monitor for signs of infection

Linchpins: (Key Points)

• Either fracture can have neurovascular compromise
• Open fractures have higher risk of infection
• Surgical consult needed on open fractures

Fat Embolus Triad:

• Respiratory Changes (hypoxia, dyspnea)
• Neurologic Changes (Altered Mental Status)
• Dermatological Changes (Petechial Rash)