Evaluation of potential fat emboli during placement of intramedullary nails after orthopedic fractures.

STUDY OBJECTIVE

To evaluate material with high echogenicity demonstrated by transesophageal echocardiography (TEE) during the reamed intramedullary nailing procedure in long-bone fracture patients, and to analyze BAL fluid (BALF) in these patients as well as in those with the fat embolism syndrome (FES).

DESIGN

Prospective cohort study.

SETTING

Emergency and critical care center of a university hospital.

PATIENTS

Fifteen patients with long-bone fractures in whom reamed intramedullary nailing was performed, and five patients diagnosed with FES.

MEASUREMENTS

During reamed nailing procedures, TEE was performed. We measured the differential cell counts, percentage of lipid-laden cells, and albumin concentration in BALF after the operation. We compared TEE findings and BALF analysis in the surgical patients. In addition, we compared BALF findings in the surgical patients and in the FES patients.

RESULTS

We divided 15 patients who underwent TEE into three subtypes based on the appearance of embolic material within the chambers of the right heart. The lipid-laden cells in BALF increased significantly in those patients with highly echogenic material by TEE (p < 0.05). The percentage of the lipid-laden cells in BALF was not significantly different between the TEE patients and those with FES. On the other hand, FES patients showed a statistically significant increase in leukocyte counts and albumin concentration (p < 0.05).

CONCLUSIONS

The highly echogenic material seen in TEE during reamed intramedullary nailing could be fat globules on the basis of BALF analysis. However, all patients with large emboli by TEE do not develop FES. A factor other than mechanical obstruction by fat globules may be necessary for the development of FES.