CASE PRESENTATION
A 19-year-old male, without past medical history, was admitted to the emergency department 4 days after an endomedullary nailing of the right femur. He was hospitalized in another hospital after a crash with his motorcycle resulting in a right-sided mid-femoral fracture. An endomedullary nailing with an 340mm long nail was performed and intraoperatively no complications were reported. (Figure 1) There was an uncomplicated postoperative course and the patient could leave the hospital the day after the operation. However, he presented at the emergency department with dyspnoea lasting for 24 hours. He had an important reduced tolerance of physical activity. At admission pulse oximetry revealed oxygen saturation of 89% on room air. On auscultation the chest was clear, his respiratory rate was 24 breaths per minute and he could speak in full sentences. He was agitated and a slightly confused. With three litres of oxygen the saturation was 97%.
Arterial blood gas analyses showed pH: 7.46 – pCO2: 32.2kPa – pO2: 57.3kPa – saturation 89%. Blood analyses revealed a CRP of 27 mg/L, white blood cell count was 15.47 x 10*9/L, normal kidney function, d-dimers of more than 4400ng/ml and elevated CK of 2760 U/L.
Echocardiography showed normal function of the left ventricle, normal valve function and normal contractility of the right ventricle without right ventricle overload.
A Computed Tomography (CT) pulmonary angiogram was performed because of a high suspicion of pulmonary embolism. The CT revealed no pulmonary embolism but demonstrated diffuse patchy ground glass appearance in the lobes of both lungs. The diagnosis of fat embolism was made.