Prolonged Coma after Unreamed, Locked Nailing of Femoral Shaft Fracture
USING transesophageal echocardiography, echogenic material can be shown in the right ventricle during many orthopedic procedures. 1 Recently, transcranial Doppler-recorded microembolic signals have been described during femoral fracture fixation, suggesting that medullary pressurization may be associated with systemic microembolism and pulmonary fat and marrow emboli. 2 Although reamed, locked intramedullary nailing is the procedure of choice for most femoral shaft fractures, some investigators
... advocate the use of smalldiameter, locking, unreamed nails to decrease the risk of fat emboli. 3,4 We report a case of severe intraoperative fat embolism after an unreamed locked intramedullary nailing. Case Report A previously healthy 17-yr-old woman was injured on her right side by a motor vehicle. At arrival to our hospital, she was fully awake and alert. There was no evidence of head, chest, or abdominal injuries. She reported pain in the right thigh and the pelvis and had an 8-cm laceration on her right hip. Her heart rate was 130 beats/min (electrocardiography showed sinus tachycardia) and her respiratory rate was 24 breaths/min. Blood pressure was 115/75 mmHg. Laboratory investigations showed mild acidosis (pH; 7.32; partial pressure of carbon dioxide [PCO 2 ]: 42 mmHg; partial pressure of oxygen [PO 2 ]: 183 mmHg; fraction of inspired concentration of oxygen [FIO 2 ]: 0.4) and hemoglobin concentration was 11.7 g/dl, with a platelet count of 357 ϫ 10 9 /l. Radiographs showed a stable lateral-compression-type pelvic fracture and a displaced, transverse, right femoral shaft fracture. Radiographs of cervical, thoracic, and lumbar sections of the spine were normal, as was the chest radiograph. Fourteen hours after injury, oxygen saturation as measured by pulse oximetry (SpO 2 ) before induction of general anesthesia was 98% breathing oxygen (FIO 2 ϭ 0.5). The patient was alert, cooperative, and recalled the accident and all events after injury (Glasgow Coma Scale ϭ 15). Vital signs were normal; however, heart rate was 130 beats/min. Anesthesia was induced using midazolam, fentanyl citrate, and propofol. Tracheal intubation was facilitated using succinylcholine. The patient underwent ventilation using oxygen in air. Anesthesia was maintained with isoflurane, intravenous fentanyl, and morphine. Vecuronium was used to provide muscle relaxation.