Attending Physician Shirley Ryan AbilityLab Chicago, Illinois, United States
Case Diagnosis: A 68 year old male developed cerebral Fat Embolism Syndrome (FES) with resultant cognitive impairment following polytrauama.
Case Description: A 68 year old male was a restrained driver in a motor vehicle accident resulting in right femur fracture, displaced right tibial fracture, sternal fracture, right fourth to seventh rib fractures, and closed left bicondylar tibial plateau fracture. Twenty-four hours following femoral fracture repair with intramedullary nailing he developed altered mental status. His MRI revealed multiple punctate foci of diffusion restriction in bilateral centrum semiovale, corona radiata, and left pons, consistent with FES.
He presented for inpatient rehabilitation with cognitive impairment, weakness, and decreased mobility. His course was limited by mood disorder and deficits in attention, working memory, executive functioning, and processing speed. He was treated with Sertraline to address his mood disorder and enhance neuromotor recovery. His functional deficits and mood improved by discharge. On outpatient follow up he presented with continued cognitive impairment, adjustment disorder, and mood disorder, which benefited from neuropsychological intervention.
Discussions: Early fixation of fracture reduces the chance of developing FES. The patient developed this complication despite prompt fixation of his femoral fracture. Isolated Central Nervous System (CNS) findings in the absence of other symptoms is an uncommon presentation of FES, which typically presents with a triad of pulmonary, neurologic, and cutaneous manifestations due to systemic embolization. In the small subset of patients with isolated CNS findings, deficits are generally mild and transient in nature. This case demonstrates a unique presentation of FES resulting in significant cognitive and psychiatric sequelae that required inpatient rehabilitation and longitudinal follow up.
Conclusions: Cognitive symptoms may be a predominant presenting feature of FES in individuals with long bone fracture. Patients with persistent, significant symptoms benefit from inpatient rehabilitation and may require continual follow up.