Orthopedic Surgeon Fails to Diagnose Fat Embolism

This case involves a twenty-five-year-old female who was admitted to the hospital with a right femur shaft fracture. The woman was involved in a head-on collision, which caused her leg to be crushed in between her seat and the dashboard. She required orthopedic surgery to reset the fractured bone. The next day, the patient underwent successful intramedullary nailing for her injury. While in recovery, the woman experienced chest pain, shortness of breath, and an elevated heart rate. She told the nurse that she did not feel well. The woman also had a purple colored rash on her leg. The nurse increased the doses of her pain medications after discussing these findings with the orthopedic surgeon. The patient was not seen by the surgeon for another four hours, during which her symptoms became more pronounced. When the nurses checked on the woman during the night, she was unresponsive. Resuscitation was attempted, but she was confirmed to be in a coma, requiring life support. The woman was in a coma for one month, until her family decided to remove her from life support. It was later determined that she suffered a fat embolism, which was directly related to her fracture.

Question(s) For Expert Witness

1. Did this orthopedic surgeon practice the standard of care when managing this patient, and, if not, what should have been done to prevent the death of this woman?

Expert Witness Response

The orthopedic surgeon failed to recognize a fat embolism in this patient. Fat embolism is a rare but serious complication of long bone fractures and trauma. Injury to the bone causes fatty acids to be released from fat globules. This injury then leads to the formation of a clot that can embolize to other organs. In this case, the embolus traveled to the pulmonary artery, causing a pulmonary embolism. Patients experiencing this condition will develop shortness of breath, tachycardia, fever, neurologic symptoms, and a characteristic petechial rash. Given these findings, fat embolism should have been worked up by ordering serum lipase levels, in addition to a full laboratory panel. The patient’s secretions should have also been examined for fat globules with either sudan or oil red staining. If the diagnosis was made, treatment is typically supportive. It is very important to maintain intravascular volume to avoid the development of shock and lung injury. This can be accomplished with intravenous fluids. More importantly, this patient should have received an anticoagulant to prevent the development of clots.