Fat embolism syndrome is an unexpected and alarming complication that is difficult to actively prevent, hard to diagnose with confidence and has limitations in effective treatment modalities. The syndrome is a melange of respiratory, haematological, neurological and cutaneous symptoms and signs associated with trauma and other disparate surgical and medical conditions. The pathogenesis is still debated. It is clear that fat emboli are quite common yet the clinical syndrome is rare. Diagnosis is by pattern recognition as befits a syndrome, but the recently defined features on MRI could now be used to increase the probability of the diagnosis. Various therapeutic options have been tried and failed. At present steroids have a single meta-analysis suggesting benefit but it is in the trauma population where they may be contra indicated for other reasons, i.e. infection, so their place is ill defined. Supportive treatment is the mainstay.