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A full assessment prompted them to order further investigations and escalate care appropriately with early critical care outreach review. This case is a useful learning tool for clinicians especially orthopaedic ward doctors. It demonstrates clearly how to recognise, investigate and manage fat embolism syndrome with a positive outcome. It is imperative that clinicians are aware of the key features of fat embolism syndrome, its significance in terms of potential deterioration and high mortality, and subsequent management of the syndrome. Learning points Fat embolism syndrome is a clinical diagnosis based on a triad of hypoxia, neurological disturbance and a petechial rash 24�C72?h after the initial insult.3 6 It is a recognised and potentially fatal complication of long bone fractures and orthopaedic reaming procedures.1�C3 Fat emboli enter the bloodstream through tissue that has been disrupted by trauma.8 The treatment is usually supportive, but may involve escalation to include ventilatory support.7 Severity can vary, but it can be associated with a mortality rate of 5�C15%.5 Footnotes Contributors: LT and JH were involved in the clinical care of the patient. LT is the main author of the case report. JH contributed by helping with the design and concept of the case report and critiquing the article to help produce a well written report. Competing interests: None. Patient consent: Obtained. Provenance and peer review: Not commissioned; externally peer reviewed.""A 15-year-old girl with a history of congenital nystagmus presented with newly recognised hyperkinetic tongue movements on protrusion without dysphagia, dysphonia or palatal myoclonus (see meprobamate online supplementary video). Contrast-enhanced MRI revealed a small lesion within the fourth ventricle abutting the dorsal medulla (figure 1). The pathology on gross total resection demonstrated a hypercellular tumour with areas of perivascular pseudorosettes consistent with a diagnosis of ependymoma (figure 2). The tongue movements did not subside following resection, indicative of possible residual infiltrative neoplasm and unlikely functional disorder. Whereas tongue tremor has been reported as a consequence of progression or treatment of glioma,1 2 this case highlights the association of hyperkinetic tongue movements as a possible presenting feature of posterior fossa ependymoma. Figure?1 MRI showing a small fourth ventricular tumour on T1 sagittal post-contrast (A) and T2 axial sequences (B) (arrowheads). Figure?2 H&E stained pathology specimen showing a cellular tumour with delicate cytoplasmic processes forming perivascular pseudorosettes characteristic of ependymoma (100�� magnification). Learning points Childhood brain tumours may have diverse presenting features depending on tumour location that may include abnormal tongue movements.