[box type=”bio”] What to Learn from this Article?[/box]
1. Serious events like Fat Embolism can occur in low risk cases of long bone fracture and the infrastructure and expertise should be ready to tackle any such situation?
Case Snippet | Volume 3 | Issue 1 | JOCR Jan – March 2013 | Page 32-33
Authors: Chandra Prakash Pal , Harish Kumar , Karuna Shankar Dinkar , Alok Agrawal 
 Department of Orthopaedics, S.N. Medical college, Agra, U.P. India
Department of Orthopaedics, Safdarjung hospital New Delhi, India
Address of Correspondence: Dr. Chandra Parkash Pal,Department of Orthopaedics, S.N. Medical college, Agra, U.P. India. Email: firstname.lastname@example.org
Incidence of Fat embolism syndrome (FES) in fractures is about 16.3 but sometimes it is as high as 50% to 62% .The fat embolism is common in fatty bed ridden patients and in whom reamed interlocking is performed under tourniquet with prolonged injury-surgery interval. However in the case discussed here FES occurred under the exact opposite circumstances. In this 23 year lean and thin female with closed tibia fracture unreamed interlocking was performed without tourniquet & the operative procedure was done within 4 hours after trauma. Her pre-operative investigation were within normal limit. We want to discuss by this case report to highlight that even when risk factors are absent outlier events of FES can occur in any case and symptoms should not be discounted.
Keywords: Fat embolism, tibia fracture, unreamed nail
Paraganglioma is benign and slow growing neuroectodermal tumor commonly found in the adrenal medulla, carotid body and glomus-jugulare . Paraganglioma of cauda equina is relatively rare, only a few 100s of cases are being reported in literature[1,2,3]. We report a case of paraganglioma of the cauda equina region who underwent successful surgical resection.
A 60year old lady presented with low back pain for a period of 1year. The pain was continuous, nagging and radiating down to her right foot. There was no complains of bowel or bladder disturbances. No past history of trauma, diabetes, hypertension or antitubercular medications. On examination, she had local tenderness in the lumbosacral region. Spinal curvature was normal. Femoral stretch test was positive indicating a lesion around L3-4 root. Neurological examination revealed sensory deficits in the distribution of L3-4 region of the right leg. The plain X-ray of the lumbosacral region was normal. The MRI of Lumbosacral spine showed a mass 2.1×1.03cm sized space occupying lesion isointense to cord, extra medullary intradural lesion at the level of L3 vertebral body (Fig 1a & b). A diagnosis of intradural extra medullary lesion was made. Possibility of meningioma, schwannoma was considered in the differential diagnosis.
She was posted for laminectomy at L3-4 level for tumor resection. Intraopeatively the tumor -a red encapsulated and firm mass found attached to a nerve root at L3 level. It was soft, grayish purple in colour and moderately vascular. Cut section showed grey brown with grey white area.
The postoperative course was uneventful with complete disappearance of pain and the neurological examination was normal.
Histopathology examination of the encapsulated lesion showed tumor cells arranged in a well defined nest of organized pattern (“Zellballen”Fig-3a) separated by thin vascularized stroma Fig-3b).
Paraganglioma is tumor derived embryologically from autonomic nervous system commonly from adrenal medulla or occasionally from extra-adrenal paraganglion system.These is collections of neural crest derived, neurosecretory and chemoreceptor cells of the autonomic nervous system belonging to a ‘diffuse neuro-endocrine system’ or the APUDsystem (Amine Precursor Uptake Decarboxylase)  with the possibility of hormone secretion (Adrenaline, noradrenaline and dopamine) .Paraganglioma of CNS is a very rare finding. The first reports dates back to 1970 by Lerhman and Kaplan . In the cauda equina region, they may arise from paraganglia located in the cauda equina, but it has also been suggested that some constituents of the diffuse neuro-endocrine system can be the result of a local differentiation from tissues not derived from the neural crest, and the participation of the ependymal cells in their development cannot be excluded  explaining the reason for the non-secretory type.It’s more common in male subpopulation and the mean age of presentation is from 13 to 70 years (mean age= 48, 45 years). Patients commonly present with low-back-ache with radicular pain as in our patient.
These tumors are misdiagnosed as meningioma or schwannomas or ependymoma because of their rarity and vascularity . MRI is the investigation of choice.The MRI characteristics of paraganglioma of cauda equina region have been well studied [1,2,4,5]. Typically paraganglioma appear isointense to the conus medullaris on T1- weighted sequences and hyperintense on T2, as seen in our case, because of high vascularity these tumors flair up with contrast study. Total surgical excision is the best option to achieve greater chance of cure and also the option to reduce the recurrences 
Although the clinical presentation and imaging appearances of paraganglioma involving the spine is nonspecific. Paraganglioma should be kept in mind as the differential diagnosis of extra medullary tumours contracted in the cauda equina region. Catecholamine secretory paraganglioma is uncommon but preoperative screening for hyper adrenergic state is necessary to prevent hypertensive crises during tumor removal.
1. Yang SY, Jin YJ, Park SH, Jahng TA, Kim HJ, Chung CK. Paragangliomas in the cauda equina region: Clinicopathoradiologic findings in four cases. J Neurooncol 2005; 72:49-55.
2. Aghakhani N, George B, Parker F. Paraganglioma of the cauda equina region-report of two cases and review of the literature. Acta Neurochir (Wien) 1999;141:81-7.
3. Gelabert-Gonzalez M. Paragangliomas of the lumbar region. Report of two cases and review of the literature. J Neurosurg Spine 2005;2:354-65.
4. Araki Y, Ishida T, Ootani M, Yamamoto H, Yamamoto T, Tsukaguchi I, et al. MRI of paraganglioma of the cauda equina. Neuroradiology 1993;35:232-3.
5. Taira H, Takasita M, Yoshida S, Takita C, Tsumura H, Torisu T. MR appearance of paraganglioma of the cauda equina. Case reports. Acta Radiol 2000;41:27-30.
6. Harrisons’s principles of internal medicine, 17th edn. McGraw-Hill, New York, Chap-337.
How to Cite This Article: Pal CP, Kumar H, Dinkar KS, Agrawal A, . Fat Embolism Syndrome in Fracture Tibia Treated by Unreamed Interlocking Nail. Journal of Orthopaedic Case Reports 2013 Jan-March;3(1): 32-33. Available from: https://www.jocr.co.in/wp/wp-content/uploads/Jan-March-2013-Article-10.pdf
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