YOUNG FEMORAL FRACTURE

   Explain what this radiograph shows and describe how you would manage this patient in the emergency department.

This is an AP radiograph of the left femur. It shows a displaced midshaft diaphyseal fracture of the femur.

Following the initial trauma assessment along ATLS guidelines, I would com- plete a full history and examination including a close examination for any evidence of open wounds and an assessment of the neurological and vascular state of the limb. I would obtain additional imaging to examine the joint above and below in AP and lateral planes. This would either be a trauma CT or additional plain radio- graphs. I would ensure that the patient had adequate analgesia and I would set up skin traction in the first instance in order to improve analgesia, realign the fracture, reduce blood loss, possibly reduce the risk of fat embolism and reduce any tension on the soft tissues. I would reassess the neurovascular status following this.

I would examine the patient carefully, performing a secondary survey in order to identify any additional or occult injuries. I would admit the patient to a ward and prepare him for surgery.

   When would you choose to take this patient to theatre and what procedure would you perform?

In an otherwise stable patient admitted during daylight hours and where they had been or could be appropriately fasted, I would aim to complete surgical treatment ideally on the same day. Should the patient be admitted late in the day, out of hours or where there are complicating factors such as reversible factors or injuries that can be treated to improve outcome, I would delay treatment to the next day routine trauma operating list or when they are best able to tolerate the anaesthetic and sur- gical insult.

3.    Several hours after surgery, the patient becomes confused, hypoxic and develops a petechial rash over his anterior chest wall. How would you manage and investi- gate this? What would be in your differential diagnosis?

I would assess the patient fully, taking a history, if possible, and perform an exami- nation of the patient. I would look particularly for signs or evidence of fever, tachy- cardia, chest pain, tachypnoea and agitation. I would take an arterial blood gas sample as well as blood samples for full blood count and urea and electrolytes. I would administer high-flow oxygen and would obtain a chest radiograph and elec- trocardiogram also. If the patient’s level of consciousness was significantly altered or evolving, then I would arrange CT imaging of the head to look for evidence of a missed intracranial bleed. A computer tomography pulmonary angiography (CTPA) would confirm or exclude a pulmonary embolus.

My differential diagnosis would include fat embolus syndrome, PE, postoperative delirium, intracranial bleed and infection. Of these, fat embolus syndrome seems the most likely to me, but this is a clinical diagnosis and I would need to exclude the more serious conditions I am considering. If the diagnosis is fat embolus syn- drome, the treatment is supportive with oxygenation, intravenous fluids, ventilation if required and close monitoring. I would expect the condition to resolve within 72 hours in most cases. Diagnosis of fat embolus syndrome is usually based on at least