Review article Fat embolism syndrome: State-of-the-art review focused on pulmonary imaging findings Katrina Newbigin a, 1 , Carolina A. Souza b, 2 , Carlos Torres b, 2 , Edson Marchiori c, 3 , Ashish Gupta b, 2 , Joao Inacio b, 2 , Mitchel Armstrong b, 4 , Elena Pe ~ na b, 2, * a Wesley Hospital, Brisbane, Australia b The Ottawa Hospital, Ottawa, Ontario, Canada c Federal University of Rio de Janeiro, Rio de Janeiro, Brazil article info Article history: Received 30 March 2015 Received in revised form 22 October 2015 Accepted 28 January 2016 Available online 1 February 2016 Keywords: Fat embolism Non thrombotic pulmonary embolism High resolution computed tomography Pulmonary imaging abstract Background: Fat embolism syndrome (FES) is a rare but potentially fatal complication of trauma or or- thopedic surgery, which presents predominantly with pulmonary symptoms. Modern intensive care has improved the mortality rates, however diagnosis remains difficult, relying predominantly on a combi- nation of a classic triad of symptoms and non-specific, but characteristic radiological features. The aim of this review is to describe the main clinical and imaging aspects of FES, ranging from pathophysiology to treatment with emphasis on pulmonary involvement. Methods: We reviewed the currently published literature on the main characteristics of FES. Results: In a hypoxic patient with recent trauma or orthopedic surgery, the presence of diffuse, well- demarcated ground glass opacities or ill-defined centrilobular nodules on computed tomography (CT) of the chest are suggestive of FES. Conclusions: Combination of the classic clinical syndrome in the appropriate clinical setting, together with the characteristic imaging findings on chest CT, can help to achieve the correct diagnosis. Man- agement remains predominantly supportive care, and the benefit of medical therapies such as cortico- steroids and heparin remains unclear. © 2016 Elsevier Ltd. All rights reserved. Contents 1. Introduction ....................................................................................................................... 94 2. Definition and classification ......................................................... ................................................ 94 3. Epidemiology ...................................................................................................................... 94 4. Pathophysiology .............................................................. ..................................................... 94 4.1. The mechanical theory ........................................................ ................................................ 94 4.2. The biochemical theory ........................................................................................................ 94 5. Diagnosis ......................................................................................................................... 95 6. Clinical manifestations .............................................................................................................. 95 7. Biochemical testing and bronchoalveolar lavage in FES .................................................................................. 95 Abbreviations: FES, fat embolism syndrome; CT, computed tomography; ARDS, adult respiratory distress syndrome; HRCT, high-resolution computed tomography; MR, magnetic resonance imaging; DWI, diffusion-weighted images. * Corresponding author. E-mail addresses: [email protected] (K. Newbigin), [email protected] (C.A. Souza), [email protected] (C. Torres), [email protected] (E. Marchiori), ashgupta@ toh.on.ca (A. Gupta), [email protected] (J. Inacio), [email protected] (M. Armstrong), [email protected] (E. Pe~ na). 1 Department of Radiology, Wesley Hospital, 2 Chasley St, Auchenflower, Brisbane, QLD, 4066, Australia. 2 Department of Medical Imaging, Ottawa Hospital Research Institute, The Ottawa Hospital, University of Ottawa, 501 Smyth Road, Box 232, K1H8L6, Ottawa, ON, Canada. 3 Department of Radiology, Federal University of Rio de Janeiro, Rua Thomaz Cameron, 438, Valparaíso, CEP 25685-120, Petr opolis, Rio de Janeiro, RJ, Brazil. 4 Department of Orthopedic Surgery, Ottawa Hospital Research Institute, The Ottawa Hospital, University of Ottawa, 501 Smyth Road, Box 232, K1H8L6, Ottawa, ON, Canada. Contents lists available at ScienceDirect Respiratory Medicine journal homepage: www.elsevier.com/locate/rmed http://dx.doi.org/10.1016/j.rmed.2016.01.018 0954-6111/© 2016 Elsevier Ltd. All rights reserved. Respiratory Medicine 113 (2016) 93e100
Fat embolism syndrome: State-of-the-art review focused on pulmonary imaging findings
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Fat embolism syndrome: State-of-the-art review focused on pulmonary imaging findingsContents lists avai
Fat embolism syndrome: State-of-the-art review focused on pulmonary imaging findings
Katrina Newbigin a, 1, Carolina A. Souza b, 2, Carlos Torres b, 2, Edson Marchiori c, 3, Ashish Gupta b, 2, Joao Inacio b, 2, Mitchel Armstrong b, 4, Elena Pe~na b, 2, *
a Wesley Hospital, Brisbane, Australia b The Ottawa Hospital, Ottawa, Ontario, Canada c Federal University of Rio de Janeiro, Rio de Janeiro, Brazil
a r t i c l e i n f o
Article history: Received 30 March 2015 Received in revised form 22 October 2015 Accepted 28 January 2016 Available online 1 February 2016
Keywords: Fat embolism Non thrombotic pulmonary embolism High resolution computed tomography Pulmonary imaging
Abbreviations: FES, fat embolism syndrome; CT, co magnetic resonance imaging; DWI, diffusion-weighte * Corresponding author.
E-mail addresses: [email protected] (K. Newb toh.on.ca (A. Gupta), [email protected] (J. Inacio), mit
1 Department of Radiology, Wesley Hospital, 2 Cha 2 Department of Medical Imaging, Ottawa Hospital 3 Department of Radiology, Federal University of Ri 4 Department of Orthopedic Surgery, Ottawa Hosp
Canada.
a b s t r a c t
Background: Fat embolism syndrome (FES) is a rare but potentially fatal complication of trauma or or- thopedic surgery, which presents predominantly with pulmonary symptoms. Modern intensive care has improved the mortality rates, however diagnosis remains difficult, relying predominantly on a combi- nation of a classic triad of symptoms and non-specific, but characteristic radiological features. The aim of this review is to describe the main clinical and imaging aspects of FES, ranging from pathophysiology to treatment with emphasis on pulmonary involvement. Methods: We reviewed the currently published literature on the main characteristics of FES. Results: In a hypoxic patient with recent trauma or orthopedic surgery, the presence of diffuse, well- demarcated ground glass opacities or ill-defined centrilobular nodules on computed tomography (CT) of the chest are suggestive of FES. Conclusions: Combination of the classic clinical syndrome in the appropriate clinical setting, together with the characteristic imaging findings on chest CT, can help to achieve the correct diagnosis. Man- agement remains predominantly supportive care, and the benefit of medical therapies such as cortico- steroids and heparin remains unclear.
© 2016 Elsevier Ltd. All rights reserved.
Contents
1. Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 94 2. Definition and classification . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 94 3. Epidemiology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 94 4. Pathophysiology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 94
4.1. The mechanical theory . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 94 4.2. The biochemical theory . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 94
5. Diagnosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 95 6. Clinical manifestations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 95 7. Biochemical testing and bronchoalveolar lavage in FES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 95
mputed tomography; ARDS, adult respiratory distress syndrome; HRCT, high-resolution computed tomography; MR, d images.
igin), [email protected] (C.A. Souza), [email protected] (C. Torres), [email protected] (E. Marchiori), ashgupta@ [email protected] (M. Armstrong), [email protected] (E. Pe~na). sley St, Auchenflower, Brisbane, QLD, 4066, Australia. Research Institute, The Ottawa Hospital, University of Ottawa, 501 Smyth Road, Box 232, K1H8L6, Ottawa, ON, Canada. o de Janeiro, Rua Thomaz Cameron, 438, Valparaíso, CEP 25685-120, Petropolis, Rio de Janeiro, RJ, Brazil. ital Research Institute, The Ottawa Hospital, University of Ottawa, 501 Smyth Road, Box 232, K1H8L6, Ottawa, ON,
8. Thoracic imaging manifestations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 95 8.1. Chest radiograph . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 95 8.2. Computed tomography of the chest . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 96
8.2.1. Patchy ground-glass opacities and consolidations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 96 8.2.2. Small centrilobular nodules . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 96 8.2.3. Other CT findings . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 96
9. Differential diagnosis of FES on chest CT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 97 10. Imaging findings in cerebral fat embolism . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 97 11. Clinical course and prognosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 98 12. Management and treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 98 13. Prevention . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 98 14. Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 98
Conflict of interest statement . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 99 Acknowledgments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 99 References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 99
1. Introduction
Traumatic fat embolism syndrome (FES) is a rare entity, usually occurring after long bone fracture or orthopedic surgery and is classically described as triad of pulmonary, central nervous system and skin manifestations. Although first described by Zenker in 1861 [1], the diagnosis of FES remains challenging due to non-specific symptoms, with respiratory symptoms dominating the clinical picture in 90% of cases. These are indistinguishable from othermore common causes of respiratory distress, in the post-traumatic and post-operative period, due to the lack of reliable diagnostic labo- ratory tests. Thoracic imaging, particularly thoracic computed to- mography (CT), is the imaging modality of choice in the investigation of pulmonary complications, playing an important role in the diagnosis of FES and alternative differentials. The aim of this article is to provide a comprehensive review of the clinical and imaging manifestations of FES and the underlying pathological process behind the imaging appearances.
2. Definition and classification
Long bone fractures and orthopedic surgery disrupt intra- medullary fat in 95% of cases but only a minority of patients develop clinical symptoms [2].…
Fat embolism syndrome: State-of-the-art review focused on pulmonary imaging findings
Katrina Newbigin a, 1, Carolina A. Souza b, 2, Carlos Torres b, 2, Edson Marchiori c, 3, Ashish Gupta b, 2, Joao Inacio b, 2, Mitchel Armstrong b, 4, Elena Pe~na b, 2, *
a Wesley Hospital, Brisbane, Australia b The Ottawa Hospital, Ottawa, Ontario, Canada c Federal University of Rio de Janeiro, Rio de Janeiro, Brazil
a r t i c l e i n f o
Article history: Received 30 March 2015 Received in revised form 22 October 2015 Accepted 28 January 2016 Available online 1 February 2016
Keywords: Fat embolism Non thrombotic pulmonary embolism High resolution computed tomography Pulmonary imaging
Abbreviations: FES, fat embolism syndrome; CT, co magnetic resonance imaging; DWI, diffusion-weighte * Corresponding author.
E-mail addresses: [email protected] (K. Newb toh.on.ca (A. Gupta), [email protected] (J. Inacio), mit
1 Department of Radiology, Wesley Hospital, 2 Cha 2 Department of Medical Imaging, Ottawa Hospital 3 Department of Radiology, Federal University of Ri 4 Department of Orthopedic Surgery, Ottawa Hosp
Canada.
a b s t r a c t
Background: Fat embolism syndrome (FES) is a rare but potentially fatal complication of trauma or or- thopedic surgery, which presents predominantly with pulmonary symptoms. Modern intensive care has improved the mortality rates, however diagnosis remains difficult, relying predominantly on a combi- nation of a classic triad of symptoms and non-specific, but characteristic radiological features. The aim of this review is to describe the main clinical and imaging aspects of FES, ranging from pathophysiology to treatment with emphasis on pulmonary involvement. Methods: We reviewed the currently published literature on the main characteristics of FES. Results: In a hypoxic patient with recent trauma or orthopedic surgery, the presence of diffuse, well- demarcated ground glass opacities or ill-defined centrilobular nodules on computed tomography (CT) of the chest are suggestive of FES. Conclusions: Combination of the classic clinical syndrome in the appropriate clinical setting, together with the characteristic imaging findings on chest CT, can help to achieve the correct diagnosis. Man- agement remains predominantly supportive care, and the benefit of medical therapies such as cortico- steroids and heparin remains unclear.
© 2016 Elsevier Ltd. All rights reserved.
Contents
1. Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 94 2. Definition and classification . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 94 3. Epidemiology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 94 4. Pathophysiology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 94
4.1. The mechanical theory . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 94 4.2. The biochemical theory . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 94
5. Diagnosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 95 6. Clinical manifestations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 95 7. Biochemical testing and bronchoalveolar lavage in FES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 95
mputed tomography; ARDS, adult respiratory distress syndrome; HRCT, high-resolution computed tomography; MR, d images.
igin), [email protected] (C.A. Souza), [email protected] (C. Torres), [email protected] (E. Marchiori), ashgupta@ [email protected] (M. Armstrong), [email protected] (E. Pe~na). sley St, Auchenflower, Brisbane, QLD, 4066, Australia. Research Institute, The Ottawa Hospital, University of Ottawa, 501 Smyth Road, Box 232, K1H8L6, Ottawa, ON, Canada. o de Janeiro, Rua Thomaz Cameron, 438, Valparaíso, CEP 25685-120, Petropolis, Rio de Janeiro, RJ, Brazil. ital Research Institute, The Ottawa Hospital, University of Ottawa, 501 Smyth Road, Box 232, K1H8L6, Ottawa, ON,
8. Thoracic imaging manifestations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 95 8.1. Chest radiograph . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 95 8.2. Computed tomography of the chest . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 96
8.2.1. Patchy ground-glass opacities and consolidations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 96 8.2.2. Small centrilobular nodules . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 96 8.2.3. Other CT findings . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 96
9. Differential diagnosis of FES on chest CT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 97 10. Imaging findings in cerebral fat embolism . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 97 11. Clinical course and prognosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 98 12. Management and treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 98 13. Prevention . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 98 14. Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 98
Conflict of interest statement . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 99 Acknowledgments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 99 References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 99
1. Introduction
Traumatic fat embolism syndrome (FES) is a rare entity, usually occurring after long bone fracture or orthopedic surgery and is classically described as triad of pulmonary, central nervous system and skin manifestations. Although first described by Zenker in 1861 [1], the diagnosis of FES remains challenging due to non-specific symptoms, with respiratory symptoms dominating the clinical picture in 90% of cases. These are indistinguishable from othermore common causes of respiratory distress, in the post-traumatic and post-operative period, due to the lack of reliable diagnostic labo- ratory tests. Thoracic imaging, particularly thoracic computed to- mography (CT), is the imaging modality of choice in the investigation of pulmonary complications, playing an important role in the diagnosis of FES and alternative differentials. The aim of this article is to provide a comprehensive review of the clinical and imaging manifestations of FES and the underlying pathological process behind the imaging appearances.
2. Definition and classification
Long bone fractures and orthopedic surgery disrupt intra- medullary fat in 95% of cases but only a minority of patients develop clinical symptoms [2].…
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