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What Causes Chest Pain And Breathing Difficulty After A Femoral Fracture Surgery?
Question: My son is 20 , recently 1/52 ago (sat 12th april Discharged friday 18th April.)had MBA in Bush , Speed 70-80km hr hit large metal pipe across bush track and went over handle bars . Not found for 2 hrs, fractured femur just above knee, plus other bruising. Operated on 24 hrs later.
Post op pain was hard to keep under control and had one code blue episode due to "overdose of PCA fentanyl.Also agitatiove Mental state more so than 'normal.'" Upon discharge was having orthostatic hypertensive episodes with chest pain and difficulty with catching breath and c/o upper lft abdominal pain that went through to back also, went grey/white during this time, pain and swelling to knee increased and temperature elavated to 39.4 degrees. Returned to hospital via ambulance, in ED commenced on QID panadol morphine and antibiotics IV , was re-admitted temp went down ...obviously. Blood tests state nil infection so antibiotics ceased. Haemoglobin is 83. was 86 when first admitted. during this second 48 hr admission Had Head CT and ultrasound to abdomen. these were clear. Remains low grade temps of 37.6 37.8 on QID paracetomol and appears to be worse in the evening, with him requesting aircon to be turned off, shivering and requesting extra blankets. He was transferred to a smaler country hospital (where he lives) with follow up physio. His temp elevated agin to 38.6 first night and haemoglobin remains low. He states he "feels tired and is sick of feeling "not right"
I am concerned there is something being missed. ??? could you help?
Brief Answer:
Possible pulmonary emolism
Detailed Answer:
Hi,
I am concerned about your son and personally I feet he should return to a medical facility. The symptoms that he is having are not routinely seen following a femoral fracture and surgical intervention, presumably he had a femoral intramedullary nail.
I would want to make sure that he has not suffered a pulmonary embolism ( a clot to the lung ) particularly with the history of chest pain and difficulty breathing. This could only be diagnosed on a VQ perfusion scan or a CT scan of his chest with intravenous contrast. Is he currently on aspirin or low molecular weight heparin or any other blood thinning medication?
His Hb of 83 at his age does not particularly concern me if he is otherwise fit and well. He should be able to tolerate this easily although he will feel washed out and tired for a few weeks.
If the investigations do not show a pulmonary embolism then they may show a chest infection. You do not mention whether he had a chest injury following his accident. A chest infection would be a common cause of a fever and feeling unwell at this stage of his recovery. The diagnosis could be made on physical assessment and with a chest XR or CT scan.
The other possibility is that he has an infection at the surgical site. This would manifest as redness, pain, swelling and possibly discharge at one or more of the incisions on his leg.
If he were one of my patients I would want him to return to hospital for further investigation.
I hope this helps
Best wishes
Above answer was peer-reviewed by :
Dr. Prasad
Thank you for your response.
Original admission 5th April and discharged 11th April.
ON Sat 12th April taken from home by ambulance Re admittted via ED , from there he has been transferred to smaller hospital where he currently remains.
He did have bruising over R side of chest going round to flank; and felt he did hurt this area, however poor historian as he had also lost consciousness at the time of the MBA. When he awoke; he dragged himself through the bush to a road before he was found.
What other symptoms should he have?
Should he have ongoing low 02 sats? ongoing shortness of breath?
His temperature remains high if not on Panadol! 39
Leg swelling has reduced somewhat now, and dressing is over site but he does still C/O knee pain front and underneath.
A Chest xray done in ED prior to last admission showed nil evidence of infection?
They did an ultra sound of stomach and back which showed haematoma where bruise above described on side of chest, and she did recommend a CT especially if XXXXXXX had history of C/O breathlessness and chest pain but it was not done.
What other reason s would he have a temp? No he is not any anticoagulants prophylactically , was at the start but none since.
Brief Answer:
Chest infection secondary to pulmonary contusion.
Detailed Answer:
From what you describe I would continue to focus on his chest and would be still concerned that he could have a pulmonary embolism or is developing a chest infection secondary to his pulmonary trauma.
As I mentioned earlier a contrast CT / CT pulmonary angiogram would be able to distinguish between a blood clot in the lung and infection.
I hope this helps answer your question.
Above answer was peer-reviewed by :
Dr. Raju A.T
Thank you Dr XXXXXXX
I dont want to seem silly but should the chest xray he had previously done reflect something?
Brief Answer:
There may be no changes on Xray
Detailed Answer:
If he has had a pulmonary embolus there are usually no changes on the CXR. An infection may evolve over time and so his CXR should be repeated if his shortness of breath, chest pain and fever continue.
Standard blood work may be normal. An arterial blood gas will show low oxygenation (SpO2) if he has a pulmonary embolism or chest infection.
Best wishes
Above answer was peer-reviewed by :
Dr. Prasad
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