Unfallchirurgie

, Volume 25, Issue 3–4, pp 183–192

Thromboembolische komplikationen bei patienten mit becken- und azetabulumfrakturen Diagnostik, therapie, prevention

  • Alexander Mayer
  • Norbert Vogel
  • Pol Maria Rommens
Originaiarbeit
  • 18 Downloads

Zusammenfassung

Patienten mit Becken- und Azetabulumfrakturen unterliegem einem sehr hohen Risiko, eine tiefe Bein- oder Beckenvenenthrombose mit Folgekomplikationen zu entwickeln. Die Thromboseinzidenz liegt bei 10% bis 60%. Proximale Thrombosen mit dem höchsten Embolisationsrisiko treten in 25% his 35% auf, ungefähr die Hälfte in den Beckenvenen. Eine symptomatische Lungenembolie entsteht bei einer Population mit Beckenverletzungen bei 2% bis 10%, klinisch inapparente Embolien sind wesentlich häufiger. Emboliegefährdete proximale Thrombosen werden im Oberschenkelbereich am besten mit der farbkodierten Duplexsonographie diagnostiziert, fur die Beckenetage kristallisiert sich die MRT als Diagnosemittel der Wahl heraus. Die Thromboseprophylaxe sollte mit einem niedermolekularen, gewichtsadaptierten Heparin sowie Kompressionsstrümpfen oder Fußpumpen erfolgen. Über den prophylaktischen Einsatz von Vena-cave-Filtern gibt es derzeit noch keine ausreichenden Daten über Einschlußkriterien und Kontrollgruppen, obwohl vielversprechende Ergebnisse über ihre Wirksamkeit vorliegen. Das Routinescreening sollte primär mit der Duplexsonographie durchgeführt werden; dies muß gegebenenfalls durch eine Phlebographie oder MRT ergänzt werden. Therapeutisch kommt in den meisten Fällen die intravenöse Gabe eines unfraktionierten Heparins oder die subkutane Gabe eines gewichtsadaptierten niedermolekularen Heparins in Frage.

Thromboembolic complications in patients with pelvis- and acetabular fractures. Diagnosis, therapy, prevention

Abstract

Patients with pelvic and acetabular fractures are known to be at increased risk for the development of a deep vein thrombosis with thromboembolic complications. The incidence of deep vein thrombosis is between 10% and 60%. Proximal deep vein thrombosis, which is most likely to result in pulmonary embolism, occurs in 25% to 35%. Almost half of all proximal thrombi will be in the pelvic veins. Symptomatic pulmonary embolism has an incidence of 2% to 10%, a greater proportion of patients will have clinically silent embolism. Color flow duplex Doppler ultrasonography is the method of choice in the detection of proximal deep vein thrombosis of the thigh, for the pelvic veins MRI may develop as the new gold standard. Prophylaxis should include low molecular weight heparin, adapted to body weight and mechanical devices such as compression stockings or foot pumps. So far, there are no hard data about controll groups and risk factors, which lead to the insertion of a vena caval filter, although there are promising results about their efficacy. Routinely screening should be performed with duplex Doppler ultrasound, in case of uncertainty venography or MRI must be admitted. In most cases intravenous application of unfractionated heparin or subcutaneous application of low molecular weight heparin is sufficient.

Schlüsselwörter

Beckenfraktur Azetabulumfraktur Beinvenenthrombose Lungenembolie Diagnostik Therapie Prophylaxe 

Key Words

Pelvic fracture Acetabular fracture Deep vein thrombosis Pulmonary embolism Diagnosis Therapy Prophylaxis 

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Literatur

  1. 1.
    Alpert JS, Dalen JE. Epidemiology and natural history of venous thromboembolism. Prog Cardiovasc Dis 1994;36:134–8.Google Scholar
  2. 2.
    Anderson FA Jr., Wheeler HB, Goldberg RJ, et al. A population based perspective of the hospital incidence and case-fatality rates of deep vein thrombosis and pulmonary embolism. The Worcester DVT Study. Arch Int Med 1991;151:933–8.Google Scholar
  3. 3.
    Buerger PM, Peoples JB, Lemmon GW, et al. Risk of pulmonary embolism in patients with pelvic fractures. Am Surg 1993;59:505–8.Google Scholar
  4. 4.
    Carpenter JP, Holland GA, Baum RA, et al. Magnetic resonance venography for the detection of venous thrombosis: comparison with contrast venography and duplex Doppler ultrasonography. J Vasc Surg 1993;18:734–41.Google Scholar
  5. 5.
    de Valk HW, Banga JD, Wester JW, et al. Comparing subcutaneous danaparoid with intravenous unfractionated heparin for the treatment of venous thromboembolism. A randomized controlled trial. Ann Int Med 1995;123:1–9.Google Scholar
  6. 6.
    Enderson BL, Chen JP, Robinson R, et al. Fibrinolysis in multisystem trauma patients. J Trauma 1991;31:1240–6.Google Scholar
  7. 7.
    Fisher CG, Blachut PA, Salvian AJ, et al. Effectiveness of pneumatic leg compression devices for the prevention of thromboembolic disease in orthopaedic trauma patients. A prospective, randomized study of compression ultrasound alone versus no prophylaxis. J Orthop Trauma 1995;9:1–7.Google Scholar
  8. 8.
    Fürst G, Kuhn F-P, Trappe RT, Mödder U. Diagnostik der tiefen Beinvenenthrombose. Fortschr Röntgenstr 1990;152:151–8.Google Scholar
  9. 9.
    Geerts WH, Code KI, Jay RM, et al. A prospective study of venous thromboembolism after major trauma. N Engl J Med 1994;331:1601–6.Google Scholar
  10. 10.
    Geerts WH, Jay R, Code K, et al. Thromboprophylaxis after major trauma — a double blind RCT comparing LDH and the LMWH, Enoxaparin. Thromb Haemost 1995;73:284–92. abstract.Google Scholar
  11. 11.
    Ginsberg JS, Caco CC, Brill-Edwards PA, et al. Venous thrombosis in patients who have undergone major hip or knee surgery: Detection with compression us and impedance plethysmography. Radiology 1991;181:651–4.Google Scholar
  12. 12.
    Green D, Lee MY, Lin AC, et al. Prevention of thromboembolism after spinal cord injury using low-molecular-weight heparin. Ann Intern Med 1991;113:571–4.Google Scholar
  13. 13.
    Gruen GS, McClain EJ, Gruen RJ. The diagnosis of deep vein thrombosis in the multiply injured patient with pelvic ring or acetabular fractures. Orthopaedics 1995;18:253–7.Google Scholar
  14. 14.
    Haas S. Thrombose in der Unfall- und Orthopädischen Chirurgie. Prophylaxe, Diagnostik, Therapie. Unfallchirurg 1997;100:307–19.Google Scholar
  15. 15.
    Hull RD, Delmore T, Genton E, et al. Warfarin sodium versus low-dose-heparin in the long term treatment of venous thrombosis. N Engl J Med 1979;301:855–8.Google Scholar
  16. 16.
    Hull RD, Hirsh J, Carter CJ, et al. Diagnostic value of ventilation-perfusion lung scanning in patients with suspected pulmonary embolism. Chest 1985;88:819–28.Google Scholar
  17. 17.
    Imperiale TF, Speroff T. A meta-analysis of methods to prevent venous thromboembolism following total hip replacement. JAMA 1994;271:1780–5.Google Scholar
  18. 18.
    Kakkar VV, Flanc C, Howe CT, et al. Natural history of postoperative deep vein thrombosis. Lancet 1969;2:230–2.Google Scholar
  19. 19.
    Knudson MM, Collins JA, Goodman SB, et al. Thromboembolism following trauma. J Trauma 1992;32:1–11.Google Scholar
  20. 20.
    Knudson MM, Lewis FR, Clinton A, et al. Prevention of venous thromboembolism in trauma patients. J Trauma 1994;37:480–7.Google Scholar
  21. 21.
    Koopman MW, Prandoni P, Piovella F, et al. Treatment of venous thrombosis with intravenous unfractionated heparin administered in the hospital compared with subcutaneous low-molecular-weight heparin administered at home. N Engl J Med 1996;334:682–7.Google Scholar
  22. 22.
    Lensing AW, Pradoni P, Brandjes D, et al. Detection of deep vein thrombosis by real-time B-mode ultrasonography. N Engl J Med 1989;320:242–5.Google Scholar
  23. 23.
    Levine M, Gent M, Hirsh J, et al. A comparison of low-molecular-weight heparin administered primarily at home with unfractionated heparin administered in the hospital for proximal deep-vein thrombosis. N Engl J Med 1996;334:677–81.Google Scholar
  24. 24.
    Ludlam CA, Bennett B, Fox KA, et al. Guidelines for the use of thrombolytic therapy. Haemostasis and thrombosis task force of the British Committee for Standards in Haematology. Blood Coagul Fibrinolysis 1995;68:14–8.Google Scholar
  25. 25.
    Mayer A, Hansen M, Aue G, et al. Präoperative Einschätzung des thromboembolischen Risikos bei Eingriffen an den unteren Extremitäten durch Bestimmung der Gerinnungsmarker TAT und D-Dimer. In: Kinzl L, Rehm KE, Hrsg. 62. Jahrestagung der Deutschen Gesellschaft für Unfallchirurgie 1998. Hefte zu Der Unfallchirurg 1998;713-4.Abstractband.Google Scholar
  26. 26.
    Mohr AN, Silverstein MD, Murtaugh PA, et al. Prophylactic agents for venous thrombosis in elective hip surgery: mete-analysis of studies using venographic assessment. Arch Int Med 1993;153:2221–8.Google Scholar
  27. 27.
    Montgomery KD, Geerts WH, Potter HG, et al. Thromboembolic complications in patients with pelvic trauma. Clin Orthop 1996;329:68–87.Google Scholar
  28. 28.
    Montgomery KD, Potter HG, Helfet DL. Magnetic resonance venography to evaluate the deep venous system of the pelvis in patients who have an acetabular fracture. J Bone Joint Surg [Am] 1995;77:1639–49.Google Scholar
  29. 29.
    Montgomery KD, Potter HG, Helfet DL. Detection and management of proximal deep vein thrombosis in patients with acute acetabular fractures. American Orthopaedic Association Annual meeting, West Virginia, 1995.abstract.Google Scholar
  30. 30.
    Moser KM, Lemoine JR. Is embolic risk conditioned by location of deep vein thrombosis? Ann Intern Med 1981;91:439–44.Google Scholar
  31. 31.
    Mussurakis S. Compression US in isolated calf venous thrombosis. Radiology 1991;181:351–3.Google Scholar
  32. 32.
    Nordstrom M, Lindblad B, Bergqvist D, et al. A prospective study of the incidence of deep-vein thrombosis within a defined urban population. J Int Med 1992;232:155–6.Google Scholar
  33. 33.
    O'Malley KF, Ross SE. Pulmonary embolism in major trauma patients. J Trauma 1990;30:748–50.Google Scholar
  34. 34.
    Partsch H. Diagnose und Therapie der tiefen Thrombose. VASA 1996;46:Suppl:1–53.Google Scholar
  35. 35.
    Poole GV, Ward EF, Griswold JA, et al. Complications of pelvic fractures from blunt trauma. Am Surg 1992;58:225–31.Google Scholar
  36. 36.
    Raskob G, Hull R, Pineo G, et al. Relation between the time to achieve a lower limit of the APTT therapeutic range and recurrent venous thromboembolism during heparin treatment for deep-vein thrombosis. Thromb Haemost 1997;Suppl:387.Google Scholar
  37. 37.
    Rogers BR. Venous thromboembolism in trauma patients. Surg Clin North Am 1995;75:279–91.Google Scholar
  38. 38.
    Rogers BR, Shackford RR, Ricci MA, et al. Prophylactic vena caval filter insertion in selected high-risk orthopaedic patients. J Orthop Trauma 1997;11:267–72.Google Scholar
  39. 39.
    Rohrer MJ, Scheidler MG, Wheller HB, et al. Extended indications for placement of inferior vena caval filter. J Vasc Surg 1989;10:44–50.Google Scholar
  40. 40.
    Rosenthal D, McKinsey JF, Levy AM, et al. Use of the greenfield filter in patients with major trauma. Cardiovasc Surg 1994;2:52–55Google Scholar
  41. 41.
    Sassa H, Sone T, Tsuboi H, et al. Diagnostic significance of thrombin-antithrombin-III complex (TAT) and D-dimer in patients with deep venous thrombosis. Jpn Circ J 1996;60:201–6.Google Scholar
  42. 42.
    Seyer AE, Soeber AV, Dembrose FA, et al. Coagulation changes in elective surgery and trauma. Ann Surg 1981;193:210–3.Google Scholar
  43. 43.
    Wells PS, Lensing AW, Hirsh J. Graduated compression stockings in the prevention of postoperative venous thromboembolism: a meta-analysis. Arch Intern Med 1994;154:67–72.Google Scholar
  44. 44.
    Wells PS, Hirsh J, Anderson DR, et al. Comparison of the accuracy of impendance plethysmography and compression ultrasonography in outpatients with clinically suspected deep vein thrombosis. A two center paired-design prospective trial. Thromb Haemostas 1995;74:14–23.Google Scholar
  45. 45.
    Wheeler HB. Diagnosis of deep vein thrombosis. Review of clinical evaluation and impedance plethysmography. Am J Surg 1985;150:Suppl:7–11.Google Scholar

Copyright information

© Urban & Vogel 1999

Authors and Affiliations

  • Alexander Mayer
    • 1
  • Norbert Vogel
    • 2
  • Pol Maria Rommens
    • 1
  1. 1.Klinik und Poliklinik für UnfallchirurgieSt.-Josephs-HospitalsWiebaden
  2. 2.Klinik und Poliklinik für RadiologieJohannes-Gutenberg-Universität MainzMainz

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