# Situation: A 30-year-old construction worker has a closed midshaft fracture of the right femur after a fall from scaffolding. He is placed in balanced skeletal traction with a pin through the distal femur while awaiting internal fixation. He has no other injuries and no significant medical history. Forty hours after the injury he becomes restless and confused. Findings: Respiratory rate: 30/min; oxygen saturation (SpO2) 87% on room air Heart rate: 124/min; temperature 38.3 °C Skin: small nonblanching red-brown spots on the chest and axillae Which is the MOST likely cause?

> source: MyMerci (mymerci.kr)  
> url: https://mymerci.kr/pages/nclex_q.php?qn_id=630432  
> language: ko  
> subject: Nursing Practice IV — Care of Clients with Problems in Nutrition and Gastrointestinal, Metabolism and Endocrine, Perception and Coordination

## 문제

Situation: A 30-year-old construction worker has a closed midshaft fracture of the right femur after a fall from scaffolding. He is placed in balanced skeletal traction with a pin through the distal femur while awaiting internal fixation. He has no other injuries and no significant medical history.

Forty hours after the injury he becomes restless and confused. Findings:
Respiratory rate: 30/min; oxygen saturation (SpO2) 87% on room air
Heart rate: 124/min; temperature 38.3 °C
Skin: small nonblanching red-brown spots on the chest and axillae
Which is the MOST likely cause?

## 보기

1. Pulmonary embolism from a deep vein clot
2. Sepsis arising from the traction pin sites
3. Fat embolism from the long-bone fracture **✔ 정답**
4. Pneumonia from immobility in traction

**정답: 3**

## 해설

Fat embolism syndrome follows long-bone or pelvic fractures, usually 24–72 hours after injury. Fat globules lodge in the lungs, brain and skin, producing hypoxemia with tachypnea, confusion or restlessness, fever, tachycardia and a petechial rash over the chest, axillae and conjunctivae.

## 심화 해설

Putting the findings together
Forty hours after a femoral shaft fracture, the client becomes restless and confused, with a respiratory rate of 30/min, SpO2 87% on room air, heart rate 124/min, temperature 38.3 °C, and small nonblanching red-brown spots on the chest and axillae. Hypoxemia, altered mental status, and a petechial rash appearing 24 to 72 hours after a long-bone fracture form the classic triad of fat embolism syndrome. The timing, the fracture type, and especially the petechiae point to this diagnosis rather than to other causes of breathlessness.

Mechanism
After a fracture of a marrow-rich long bone such as the femur, or of the pelvis, fat globules enter the venous circulation. They lodge in the pulmonary capillaries, where they and the inflammatory free fatty acids they release damage the lungs and cause hypoxemia and tachypnea. Fat that passes into the systemic circulation blocks small vessels in the brain, producing confusion or restlessness, and in the skin, producing petechiae over the chest, axillae, and conjunctivae. Fever and tachycardia are also common. Onset is usually 24–72 hours after injury.

Differentiating the distractors
Each alternative can cause breathlessness after a fracture, but none explains every finding.

| Option | Typical features | Missing piece |
| --- | --- | --- |
| Pulmonary embolism | Sudden dyspnea, chest pain, hypoxemia | No petechial rash; early confusion of this kind is unusual |
| Pin-site sepsis | Local redness and drainage, then systemic signs | Unlikely this early; no petechiae |
| Fat embolism | Hypoxemia, confusion, petechiae, fever at 24–72 hours | Fits all findings |
| Pneumonia | Cough, sputum, fever, crackles | Takes longer to develop; no petechiae |

Watch out! Pulmonary embolism from a deep vein thrombosis is the most common distractor. Venous clots usually take longer to form, and they do not cause a petechial rash. The rash is the clue that separates the two.

Nursing implications
Fat embolism syndrome is a medical emergency. Management is supportive: oxygen, positioning to ease breathing, close monitoring of oxygen saturation and neurologic status, and ventilatory support if needed. Prevention includes early immobilization and fixation of long-bone fractures and minimal movement of the injured limb. Key point! A long-bone fracture plus hypoxemia, confusion, and petechiae within 24 to 72 hours equals fat embolism syndrome until proven otherwise.

## 임상 시나리오

Fat Embolism SyndromeAfter a long-bone fracture
At 40 hours after a femur fracture: restlessness, confusion, respiratory rate 30/min, SpO2 87%, heart rate 124/min, fever, and petechiae on the chest and axillae.

Fat globules from the marrow lodge in the lungs, brain, and skin, causing the triad of hypoxemia, neurologic change, and petechial rash, usually 24–72 hours after injury.

Care is supportive: oxygen, upright positioning, and close monitoring of breathing and mental status, with ventilatory support if needed.

CautionDo not mistake this for pulmonary embolism; the petechial rash is the distinguishing sign and must be reported.

## 핵심 개념

- **Fat embolism syndrome** — A complication of long-bone or pelvic fractures in which fat globules cause hypoxemia, confusion, and petechiae.
- **Petechiae** — Tiny nonblanching red or purple spots caused by bleeding from small skin capillaries.
- **Hypoxemia** — An abnormally low level of oxygen in the arterial blood.
- **Pulmonary embolism** — Blockage of a pulmonary artery, usually by a clot from the deep veins of the legs.

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