A 42 year-old male sustained an accidental rifle gunshot wound to his left foot, resulting in fracture deformities of the calcaneus, navicular, cuneiform, 1^st and 2^nd metatarsal bases, and talus. As he was transported to our trauma center, he developed progressive encephalopathy. Urgent external fixator placement under general anesthesia was postponed due to his encephalopathy of unknown etiology. Brain magnetic resonance imaging demonstrated a “starfield” pattern of infarcts, consistent with cerebral fat embolism syndrome. Subsequently, he underwent uneventful general anesthesia. The patient was managed supportively and continued to have persistent neurologic dysfunction two months after injury.