**20. Management**

There is no definitive therapy for FES. The treatment is mainly supportive. Maintenance of adequate oxygenation, ensuring hemodynamic stability, prophylaxis of venous thrombosis and stress related gastrointestinal bleeding and nutrition are key aspects. Therefore clinical management strategies should be geared towards prophylactic measures in trauma victims. Early stabilization of the fractures as well as early operative intervention reduces the incidence and severity of FES (Al-Khuwaitir et al., 2002; A. B. Baker, 1976; Bone et al., 1989; Jenkins et al., 2002; Johnson & Lucas, 1996; Parisi et al., 2002; Riska et al., 1976; Riska & Myllynen, 1982; Svenningsen et al., 1987; Tachakra et al., 1990; Talucci et al., 1983). Early ( < 24 hours) fixation of the fracture of the femur was associated with an improved outcome even in patients with concomitant head and chest trauma (Brundage et al., 2002). When fracture stabilization was delayed in patients with multiple injuries, the incidence of ARDS, FE and pneumonia, the costs of hospital care and the number of days in the intensive care unit (ICU) were increased (Behrman et al., 1990; Bone et al., 1989). Intraosseous pressure limitation during orthopedic procedures reduces the intravasation of intramedullary fat and other debris and therefore may reduce the incidence and severity of FES (Y. H. Kim et al., 2002; Kropfl et al., 1999; Pitto et al., 1999; Pitto et al., 2002; Pitto, Schramm et al., 1999).

Incidence and severity of FES are decreased when corticosteroids are given prophylactically, although no mortality benefit has been demonstrated (Alho et al., 1978; Bederman et al., 2009; Kallenbach et al., 1987; Lindeque et al., 1987; Schonfeld et al., 1983). Nonetheless, prophylactic use of corticosteroids remains controversial mainly because of lack of large scale studies. The results of treatment with drugs, including clofibrate, dextran-40, ethyl alcohol, heparin, and aspirin are inconclusive (K. M. Chan et al., 1984; Gossling & Pellegrini, 1982; Peltier, 1984; Shier et al., 1977; Stoltenberg & Gustilo, 1979).

## **21. Prognosis**

84 Pulmonary Embolism

Table 5. Gurd and Wilson: FES = 1 major + 4 minor + Fat microglobulinemia

• Pyrexia • Tachycardia • Retinal changes • Jaundice

rate

**Criterion Points**  Diffuse petechiae 5 Alveolar infiltrates 4 Hypoxemia <70 mm Hg 3 Confusion 1 Fever 38 C 1 Heart rate >120/min 1 Respiratory rate >30/min 1

There is no definitive therapy for FES. The treatment is mainly supportive. Maintenance of adequate oxygenation, ensuring hemodynamic stability, prophylaxis of venous thrombosis and stress related gastrointestinal bleeding and nutrition are key aspects. Therefore clinical management strategies should be geared towards prophylactic measures in trauma victims. Early stabilization of the fractures as well as early operative intervention reduces the incidence and severity of FES (Al-Khuwaitir et al., 2002; A. B. Baker, 1976; Bone et al., 1989; Jenkins et al., 2002; Johnson & Lucas, 1996; Parisi et al., 2002; Riska et al., 1976; Riska & Myllynen, 1982; Svenningsen et al., 1987; Tachakra et al., 1990; Talucci et al., 1983). Early ( < 24 hours) fixation of the fracture of the femur was associated with an improved outcome even in patients with concomitant head and chest trauma (Brundage et al., 2002). When fracture stabilization was delayed in patients with multiple injuries, the incidence of ARDS, FE and pneumonia, the costs of hospital care and the number of days in the intensive care unit (ICU) were increased (Behrman et al., 1990; Bone et al., 1989). Intraosseous pressure limitation during orthopedic procedures reduces the intravasation of intramedullary fat and other debris and therefore may reduce the incidence and severity of FES (Y. H. Kim et al., 2002; Kropfl et al., 1999; Pitto et al., 1999;

Incidence and severity of FES are decreased when corticosteroids are given prophylactically, although no mortality benefit has been demonstrated (Alho et al., 1978; Bederman et al.,

• Renal changes (anuria or oliguria) • Thrombocytopenia (a drop of >50%

 of the admission platelet count) • High erythrocyte sedimentation

• Fat macroglobulinemia

**Major Minor** 

Table 6. Schonfeld's criteria - FES = 5 or more points

Pitto et al., 2002; Pitto, Schramm et al., 1999).

**20. Management** 

• Respiratory insufficiency • Cerebral involvement

• Petechial rash

With timely supportive care and hemodynamic support, most patients with FES recover completely. Mortality rate has been variably reported to be 10 to 20% (Fabian et al., 1990; Moreau, 1974; Peltier, 1965; Peltier et al., 1974).
