The fat embolism syndrome

Abstract

The classical fat embolism syndrome comprises the symptoms of petechial rash, pulmonary distress and mental disturbances with an onset 24-48 h following a pelvic or long-bone fracture. Although the first description of the fat embolization process is ascribed to Zenker’ in an article published in 1862, he only mentioned the presence of fat in the lung capillaries of a railwayman who was caught between the bumpers of two train wagons. He sustained a crushed liver and died on the spot due to exsanguination. Obstruction of the pulmonary artery branches by plugs of fat has been described after various types of medical event: skeletal injuries, soft-tissue injuries-, pancreatitis”, extracorporeal circulatiorP, high-altitude illness: divers’ decompression illness*, sickle-cell disease’, burns”‘,“, osteomyelitiP~‘“, epilepsy’4, liposuction’5,‘h and fatty 1iveP. Many credit the first description of the classical form of the fat embolism syndrome to Bergman la. In 1873, he mentioned the clinical deterioration, after a symptom-free interval, and subsequent death of a tinsmith who fell from a roof and sustained a cornminuted femoral fracture. However, this was not the first publication on the clinical fat embolism syndrome. In this respect, the early literature is intriguing. During the 10 years after the publication by Zenker in 1862, several articles and theses appeared on the subject’2.‘~~. Besides describing causal events, the authors performed extensive animal experiments in which they tried to imitate the natural clinical course of patients with skeletal injuries. For example, fat emulsions were injected into the jugular vein, osteotomies were performed, pressure was exerted on the medullary cavity, bone particles were crushed, mixed with bone marrow and subsequently buried under the periosteum of the tibia and so on. In those days, the fat embolism syndrome was not only encountered in injured patients, but also in patients who were suffering from acute osteomyelitis or severe frostbite. At that time there was no real remedy for the illness the outcome was nearly always fatal. Since 1860, more than 2000 reports and articles have been published on the process of fat embolization and the fat embolism syndrome. The enormous quantity of literature not only illustrates the need for knowledge about the pathogenesis, but it also reflects the feelings of powerlessness of a doctor who, in a single event, is confronted by pulmonary and cerebral complications, or even the early death of a young patient with an isolated long-bone or pelvic fracture. Although it is the general feeling among clinicians that the incidence of the fat embolism syndrome today is far lower than it was a few decades ago, early recognition of the symptoms is still of major importance in preventing morbidity and mortality in patients with single and multiple skeletal injuries.