Download PDF
Z Orthop Unfall 2008; 146(5): 580-585
DOI: 10.1055/s-2008-1038542
Trauma

© Georg Thieme Verlag KG Stuttgart · New York

Verletzungsadaptiertes Vorgehen bei Unterschenkelverletzungen des Schwerverletzten

Damage Control Orthopaedics in Polytraumatised Patients with Lower Leg InjuriesP. Kobbe1 , 2 , I. S. Tarkin1 , R. Oberbeck2 , H.-C. Pape1
  • 1Department of Orthopaedic Surgery, Division of Trauma, University of Pittsburgh, USA
  • 2Abteilung für Unfallchirurgie, Universitätsklinikum Essen
Further Information

Publication History

Publication Date:
09 October 2008 (online)

Also available at
    Permissions and Reprints

Zusammenfassung

Die Art und Weise der operativen Versorgung von Frakturen des Schwerverletzten richtet sich nach der Gesamtverletzungsschwere des Patienten, weshalb dieser in eine von vier Kategorien (stabil, borderline, instabil und in extremis) eingeteilt wird. Patienten der Kategorie stabil sollten und Patienten der Kategorie borderline können einer primär definitiven Osteosynthese unterzogen werden, falls die Weichteilsituation dieses zulässt. Im Gegensatz hierzu wird bei Patienten der Kategorien instabil und in extremis keine primär definitive Osteosynthese empfohlen. Die Problematik der Unterschenkelfraktur resultiert aus der minimalen Weichteildeckung der Tibia. Die Kombination von ausgeprägtem Weichteilschaden mit offener Fraktur stellt ein erhebliches Infektionsrisiko dar. Eine besondere Herausforderung stellen bilaterale Tibiafrakturen oder ipsilaterale Tibia- und Femurfrakturen des Schwerverletzten dar. Für diese Verletzungen wurden Versorgungsalgorithmen entwickelt, die die kritische Weichteilsituation der Tibia sowie die Gesamtverletzungsschwere berücksichtigen. Die Indikationsstellung zur Kompartmentspaltung sollte beim Schwerverletzten mit Unterschenkelverletzungen großzügig gestellt werden. Die Entscheidung zur Amputation sollte vom Allgemeinzustand des Patienten sowie dem Weichteil- und neurovaskulären Status der Extremität abhängig gemacht werden. Score-Systeme können zur Entscheidungshilfe herangezogen werden, die Entscheidung hinsichtlich des Extremitätenerhalts sollte allerdings immer individuell getroffen werden.

Abstract

In polytraumatised patients, fracture management depends on the overall injury severity. For decision making, patients are grouped in one of four categories (stabile, borderline, instable and in extremis). Stabile patients should and borderline patients may undergo primary definitive fracture stabilisation; in contrast, this is not recommended for instable or in extremis patients. The marginal soft tissue envelope of the tibia predisposes for open fractures, compartment syndrome, and wound infections. Therefore the management of lower leg injuries is demanding, especially in polytraumatised patients. Bilateral tibia fractures and ipsilateral tibia and femur fractures represent a special entity. For these injuries special algorithms, which consider the soft tissue status of the tibia and the overall injury severity, have been developed. The indication for fasciotomy covers a wide field and may be performed prophylactically. The decision for amputation is based on the patient's general condition and the soft-tissue and neurovascular status. Scoring systems are useful for decision making, however individual decisions should be made.

Schlüsselwörter

Unterschenkelverletzung - Polytrauma - verletzungsadaptiertes Vorgehen - Amputation

Key words

lower leg injuries - polytrauma - damage control orthopaedics - amputation

Literatur

  • 1 Amgwerd M G, Trentz O, Schutz K, Meyer V. [Concept for the management of combined bone-soft tissue defects of the lower extremity].  Swiss Surg. 1995;  2 90-95
    PubMedGoogle Scholar
  • 2 Bastian L, Blauth M, Thermann H, Tscherne H. [Various therapy concepts in severe fractures of the tibial pilon (type C injuries). A comparative study].  Unfallchirurg. 1995;  98 551-558
    PubMedGoogle Scholar
  • 3 Blachut P A, Meek R N, O'Brien P J. External fixation and delayed intramedullary nailing of open fractures of the tibial shaft. A sequential protocol.  J Bone Joint Surg Am. 1990;  72 729-735
    PubMedGoogle Scholar
  • 4 Blauth M, Bastian L, Krettek C, Knop C, Evans S. Surgical options for the treatment of severe tibial pilon fractures: a study of three techniques.  J Orthop Trauma. 2001;  15 153-160
    CrossrefPubMedGoogle Scholar
  • 5 Bondurant F J, Cotler H B, Buckle R, Miller-Crotchett P, Browner B D. The medical and economic impact of severely injured lower extremities.  J Trauma. 1988;  28 1270-1273
    CrossrefPubMedGoogle Scholar
  • 6 Bosse M J, MacKenzie E J, Kellam J F, Burgess A R, Webb L X, Swiontkowski M F, Sanders R W, Jones A L, McAndrew M P, Patterson B M, McCarthy M L, Travison T G, Castillo R C. An analysis of outcomes of reconstruction or amputation after leg-threatening injuries.  N Engl J Med. 2002;  347 1924-1931
    CrossrefPubMedGoogle Scholar
  • 7 Cole J D, Ansel L J, Schwartzberg R. A sequential protocol for management of severe open tibial fractures.  Clin Orthop Relat Res. 1995;  315 84-103
    PubMedGoogle Scholar
  • 8 Court-Brown C M, McBirnie J. The epidemiology of tibial fractures.  J Bone Joint Surg [Br]. 1995;  77 (3) 417-421
    PubMedGoogle Scholar
  • 9 Dorow C, Markgraf E. [Therapy of soft tissue injuries – biological strategies].  Zentralbl Chir. 1997;  122 962-969
    PubMedGoogle Scholar
  • 10 Echtermeyer V, Horst P. [Compartment syndrome. Exclusively the result of increased pressure in the muscular compartment?].  Unfallchirurg. 1997;  100 924-937
    CrossrefPubMedGoogle Scholar
  • 11 Georgiadis G M, Behrens F F, Joyce M J, Earle A S, Simmons A L. Open tibial fractures with severe soft-tissue loss. Limb salvage compared with below-the-knee amputation.  J Bone Joint Surg [Am]. 1993;  75 1431-1441
    PubMedGoogle Scholar
  • 12 Giannoudis P V. Surgical priorities in damage control in polytrauma.  J Bone Joint Surg [Br]. 2003;  85 478-483
    CrossrefPubMedGoogle Scholar
  • 13 Gopal S, Majumder S, Batchelor A G, Knight S L, De Boer P, Smith R M. Fix and flap: the radical orthopaedic and plastic treatment of severe open fractures of the tibia.  J Bone Joint Surg [Br]. 2000;  82 959-966
    CrossrefPubMedGoogle Scholar
  • 14 Gustilo R B, Merkow R L, Templeman D. The management of open fractures.  J Bone Joint Surg [Am]. 1990;  72 (2) 299-304
    PubMedGoogle Scholar
  • 15 Hansen Jr S T. The type-III C tibial fracture. Salvage or amputation.  J Bone Joint Surg [Am]. 1987;  69 799-800
    PubMedGoogle Scholar
  • 16 Harwood P J, Giannoudis P V, Probst C, Krettek C, Pape H C. The risk of local infective complications after damage control procedures for femoral shaft fracture.  J Orthop Trauma. 2006;  20 181-189
    PubMedGoogle Scholar
  • 17 Helfet D L, Howey T, Sanders R, Johansen K. Limb salvage versus amputation. Preliminary results of the Mangled Extremity Severity Score.  Clin Orthop Relat Res. 1990;  256 80-86
    PubMedGoogle Scholar
  • 18 Krettek C, Schandelmaier P, Tscherne H. [Distal femoral fractures. Transarticular reconstruction, percutaneous plate osteosynthesis and retrograde nailing].  Unfallchirurg. 1996;  99 2-10
    PubMedGoogle Scholar
  • 19 Lange R H, Bach A W, Hansen Jr S T, Johansen K H. Open tibial fractures with associated vascular injuries: prognosis for limb salvage.  J Trauma. 1985;  25 203-208
    CrossrefPubMedGoogle Scholar
  • 20 McQueen M M, Court-Brown C M. Compartment monitoring in tibial fractures. The pressure threshold for decompression.  J Bone Joint Surg [Br]. 1996;  78 99-104
    PubMedGoogle Scholar
  • 21 Meregalli A, Oliveira R P, Friedman G. Occult hypoperfusion is associated with increased mortality in hemodynamically stable, high-risk, surgical patients.  Crit Care. 2004;  8 R60-R65
    CrossrefPubMedGoogle Scholar
  • 22 Muhr G. [Therapeutic strategies in fractures with soft tissue damage].  Chirurg. 1991;  62 361-366
    PubMedGoogle Scholar
  • 23 Oestern H J, Tscherne H. [Pathophysiology and classification of soft tissue damage in fractures].  Orthopäde. 1983;  12 2-8
    PubMedGoogle Scholar
  • 24 Pape H C, Auf'm'Kolk M, Paffrath T, Regel G, Sturm J A, Tscherne H. Primary intramedullary femur fixation in multiple trauma patients with associated lung contusion – a cause of posttraumatic ARDS?.  J Trauma. 1993;  34 540-547
    PubMedGoogle Scholar
  • 25 Pape H C, Dwenger A, Regel G, Remmers D, Tscherne H. Intramedullary femoral nailing in sheep: does severe injury predispose to pulmonary dysfunction?.  Eur J Surg. 1995;  161 163-171
    PubMedGoogle Scholar
  • 26 Pape H C, Giannoudis P, Krettek C. The timing of fracture treatment in polytrauma patients: relevance of damage control orthopedic surgery.  Am J Surg. 2002;  183 622-629
    CrossrefPubMedGoogle Scholar
  • 27 Pape H C, Krettek C. [Management of fractures in the severely injured – influence of the principle of “damage control orthopaedic surgery”].  Unfallchirurg. 2003;  106 87-96
    CrossrefPubMedGoogle Scholar
  • 28 Pape H C, Regel G, Dwenger A, Krumm K, Schweitzer G, Krettek C, Sturm J A, Tscherne H. Influences of different methods of intramedullary femoral nailing on lung function in patients with multiple trauma.  J Trauma. 1993;  35 709-716
    PubMedGoogle Scholar
  • 29 Pape H C, Remmers D, Regel G, Tscherne H. [Pulmonary complications following intramedullary stabilization of long bones. Effect of surgical procedure, time and injury pattern].  Orthopäde. 1995;  24 164-172
    PubMedGoogle Scholar
  • 30 Pape H C, Zelle B, Sittaro N A, Krettek C. The objective and subjective outcome after polytrauma: a reexamination 10 years after initial injury. 70th Annual Meeting of the American Academy of Orthopaedic Surgeons (AAOS), February 5 – 9, 2003. New Orleans, LA: AAOS, 2006. 
    Google Scholar
  • 31 Patterson M J, Cole J D. Two-staged delayed open reduction and internal fixation of severe pilon fractures.  J Orthop Trauma. 1999;  13 85-91
    CrossrefPubMedGoogle Scholar
  • 32 Regel G, Lobenhoffer P, Lehmann U, Pape H C, Pohlemann T, Tscherne H. [Results of treatment of polytraumatized patients. A comparative analysis of 3, 406 cases between 1972 and 1991].  Unfallchirurg. 1993;  96 350-362
    PubMedGoogle Scholar
  • 33 Renaldo N, Egol K. Damage-control orthopedics: evolution and practical applications.  Am J Orthop. 2006;  35 285-291
    PubMedGoogle Scholar
  • 34 Rommens P, Schmit-Neuerburg K P. Ten years of experience with the operative management of tibial shaft fractures.  J Trauma. 1987;  27 917-927
    PubMedGoogle Scholar
  • 35 Sirkin M, Sanders R, DiPasquale T, Herscovici Jr D. A staged protocol for soft tissue management in the treatment of complex pilon fractures.  J Orthop Trauma. 1999;  13 78-84
    CrossrefPubMedGoogle Scholar
  • 36 Tscherne H, Oestern H J. [A new classification of soft-tissue damage in open and closed fractures (author's transl)].  Unfallheilkunde. 1982;  85 111-115
    PubMedGoogle Scholar
  • 37 Tscherne H, Regel G. Tscherne Unfallchirurgie: Trauma-Management. Berlin; Springer 1997
    Google Scholar
  • 38 Weise K, Höntzsch D. Unterschenkelfraktur: Operative Verfahren und Verfahrenswechsel.  Trauma Berufskrankh. 2001;  3 (Suppl 2) 119-124
    CrossrefPubMedGoogle Scholar
  • 39 Whitesides T E, Heckman M M. Acute compartment syndrome: Update on diagnosis and treatment.  J Am Acad Orthop Surg. 1996;  4 209-218
    PubMedGoogle Scholar

Dr. Philipp Kobbe

Department of Orthopaedic Surgery, Division of Trauma, University of Pittsburgh

Kaufmann Medical Building, Suite 1010

3471 Fifth Avenue

Pittsburgh, PA 15213

USA

Phone: 412-605-3219

Fax: 412-687-3724

Email: kobbep@upmc.edu

      >