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Management und Outcome schwerster Extremitätenverletzungen

Aktueller Überblick

Management and outcome of extremely severe injuries of the extremities

Current overview

  • Leitthema
  • Published:
Trauma und Berufskrankheit

Zusammenfassung

Schwerste Extremitätenverletzungen („mangled extremity“) gehen mit der Zerstörung von mindestens 3 von 4 Bereichen einer Extremität (Knochen, Nerven, Gefäße, Muskel- und Weichteile) einher und stellen eine interdisziplinäre Herausforderung für Ärzte und Patient dar. Die Entscheidung pro oder kontra Extremitätenerhalt beruht auf verschiedenen Faktoren, die nur partiell in Scores abgebildet sind. Scoringsysteme [Mangled Extremity Severity Score (MESS), Predictive Salvage Index (PSI), Limb Salvage Index (LSI), Nerve Injury, Ischemia, Soft-tissue-contamination, Skeletal injury, Shock and Age (NISSA)] stellen lediglich eine Entscheidungshilfe dar, sie geben keine Aussage über das funktionelle Outcome. Die primäre Entscheidungsfindung ist daher interprofessionell und patienten- sowie situationsgerecht, also individuell zu treffen und sollte durch eine gute schriftliche und fotografische Dokumentation begleitet werden. Es zeigen sich Tendenzen eines besseren psychischen Outcomes bei Extremitätenerhalt als bei Amputation. Funktionelle Unterschiede hinsichtlich Mobilität, Belastbarkeit und Funktion konnten auch langfristig nicht nachgewiesen werden. Letztlich muss stets bedacht werden, dass eine zunächst gefällte Entscheidung zum Extremitätenerhalt durchaus im Verlauf korrigierbar ist, der umgekehrte Fall jedoch nicht. Daher sollte im Zweifelsfall ein Erhalt angestrebt werden.

Abstract

Extremely severe injuries to the extremities (mangled extremity) are accompanied by the destruction of three or four regions of the extremity (e.g. bone, soft tissue and muscle, blood vessels and nerves) and represent an interdisciplinary challenge for surgeons and patients. The decision for or against extremity salvage is based on various factors, which are only partially reflected in scores. Scoring systems, such as the mangled extremity severity score (MESS), the predictive salvage index (PSI), the limb salvage index (LSI) and the NISSA score (nerve injury, ischemia, soft tissue contamination, skeletal injury, shock and age) are only aids for decision-making but do not assist with the perspectives of long-term outcome. The primary decision must therefore be made at an interdisciplinary level, is patient-specific and should be well documented both in writing and with photographs. There is a tendency for a superior psychological outcome in patients with preserved extremities than after amputation. No long-term differences were found between amputation and salvaged limb study groups for mobility, function and ability to work. Finally, consideration must be given to the fact that the initial decision for limb salvage can be corrected but an amputation cannot; therefore, in case of doubt salvage should be strived for.

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Literatur

  1. Akula M, Gella S, Moshen A, Shaw CJ (2007) A meta-analysis of amputation versus limb salvage in a mangled lower limb. Injury 11:292–?

    Google Scholar 

  2. Beekley AC, Sebesta JA, Blackbourne LH (2008) Prehospital tourniquet use in Operation Iraqi Freedom: effect on hemorrhage control and outcomes. J Trauma 64:S28

    Article  PubMed  Google Scholar 

  3. Bosse MJ, McCarthy ML, Jones AL et al (2005) The insensate foot following severe lower extremity trauma: an indication for amputation? J Bone Joint Surg Am 87:2601

    Article  PubMed  Google Scholar 

  4. Bosse MJ, MacKenzie EJ, Kellam JF, Burgess AR, Webb LX, Swiontkowski MF, Sanders RW, Jones AL, McAndrew MP, Patterson BM, McCarthy ML, Cyril JK (2001) A prospective evaluation of the clinicaL utility of the lower extremity Injury-Severity Scores. J Bone Joint Surg Am 83(1):3–14

    Article  PubMed  Google Scholar 

  5. Belmont PJ Jr, Goodman GP, Zacchilli M (2010) Incidence and epidemiology of combat injuries sustained during „the surge“ portion of operation Iraqi Freedom by a U.S. Army brigade combat team. J Trauma 68:204

    Article  PubMed  Google Scholar 

  6. Brumback RJ, Jones AL (1994) Interobserver agreement in the classification of open fractures of the tibia. The results of a survey of two hundred and forty-five orthopaedic surgeons. J Bone Joint Surg Am 76:1162

    CAS  PubMed  Google Scholar 

  7. Bumbasirevic M, Stevanovic M, Lesic A, Atkinson HDE (2012) Current management of themmangled upper extremity. Int Orthoped (SICOT) 36:2189–2195

    Article  Google Scholar 

  8. Burkhardt GE, Cox M, Clouse WD et al (2010) Outcomes of selective tibial artery repair following combat-related extremity injury. J Vasc Surg 52:91

    Article  PubMed  Google Scholar 

  9. Cannada LK, Melton DH, Deren ME, HAyda RA, HArwey EJ (2015) Dealing with catastrophic outcomes and amputations in the mangled limb. J Orthop Trauma 29:39–42

    Article  Google Scholar 

  10. Cavadas PC, Landín L (2009) Ibáñez J:. Infrapopliteal lower extremity replantation. Plast Reconstr Surg 124:532

    Article  CAS  PubMed  Google Scholar 

  11. Cancio LC, Jimenez-Reyna JF, Barillo DJ et al (2005) One hundred ninety-five cases of high-voltage electric injury. J Burn Care Rehabil 26:331

    Article  PubMed  Google Scholar 

  12. Committee for Tactical Emergency Medical Care. Tactical Emergency Casualty Care Guidelines: Direct Threat Care. http://c-tecc.org/tactical-emergency-casualty-care-guidelines. Zugegriffen: 22. Okt. 2013

  13. Court-Brown CM, Rimmer S, Prakash U, McQueen MM (1998) The epidemiology of open long bone fractures. Injury 29:529

    Article  CAS  PubMed  Google Scholar 

  14. Court-Brown CM, McBirnie J (1995) The epidemiology of tibial fractures. J Bone Joint Surg Br 77:417

    CAS  PubMed  Google Scholar 

  15. Court-Brown CM (2006) Epidemiology of adult fractures: a review. Injury 37(8):691–697

    Article  PubMed  Google Scholar 

  16. Dillingham TR, Pezzin LE, MacKenzie EJ (1998) Incidence, acute care length of stay, and discharge to rehabilitation of traumatic amputee patients: an epidemiologic study. Arch Phys Med Rehabil 79:279

    Article  CAS  PubMed  Google Scholar 

  17. Dorlac WC, DeBakey ME, Holcomb JB et al (2005) Mortality from isolated civilian penetrating extremity injury. J Trauma 59:217

    Article  CAS  PubMed  Google Scholar 

  18. Dua A, Desai SS, Shah JO et al (2014) Outcome predictors of limb salvage in traumatic popliteal artery injury. Ann Vasc Surg 28:108

    Article  PubMed  Google Scholar 

  19. Elsharawy MA (2005) Arterial reconstruction after mangled extremity: injury severity scoring systems are not predictive of limb salvage. Vascular 13:114–119

    Article  PubMed  Google Scholar 

  20. Finkelstein EA, Corso PS, Miller TR et al (2006) The incidence and economic burden of injuries in the United States. Oxford University Press, New York

    Book  Google Scholar 

  21. Fodor L, Sobec R, Sita-Alb L, Fodor M, Ciuce C (2012) Mangled lower extremity: can we trust the amputation scores? Int J Burn Trauma 2(1):51–58

    Google Scholar 

  22. Fox N, Rajani RR, Bokhari F et al (2012) Evaluation and management of penetrating lower extremity arterial trauma: an Eastern Association for the Surgery of Trauma practice management guideline. J Trauma Acute Care Surg 73:S315

    Article  PubMed  Google Scholar 

  23. Fox CJ, Gillespie DL, O’Donnell SD et al (2005) Contemporary management of wartime vascular trauma. J Vasc Surg 41:638

    Article  PubMed  Google Scholar 

  24. Franz RW, Shah KJ, Halaharvi D et al (2011) A 5-year review of management of lower extremity arterial injuries at an urban level I trauma center. J Vasc Surg 53:1604

    Article  PubMed  Google Scholar 

  25. Frykberg ER, Dennis JW, Bishop K et al (1991) The reliability of physical examination in the evaluation of penetrating extremity trauma for vascular injury: results at one year. J Trauma 31:502

    Article  CAS  PubMed  Google Scholar 

  26. Graham B, Adkins P, Tsai TM et al (1998) Major replantation versus revision amputation and prosthetic fitting in the upper extremity: a late functional outcomes study. J Hand Surg Am 23:783

    Article  CAS  PubMed  Google Scholar 

  27. Gustilo RB, Mendoza RM, Williams DN (1984) Problems in the management of type III (severe) open fractures: a new classification of type III open fractures. J Trauma 24:742

    Article  CAS  PubMed  Google Scholar 

  28. Gustilo RB, Anderson JT (1976) Prevention of infection in the treatment of one thousand and twenty-five open fractures of long bones: retrospective and prospective analyses. J Bone Joint Surg Am 58:453

    CAS  PubMed  Google Scholar 

  29. Harboe K, Søreide K (2012) Tibial fracture with degloving injury of the foot. Br J Surg 99(Suppl 1):87

    Article  PubMed  Google Scholar 

  30. Harris AM, Althausen PL, Kellam J et al (2009) Complications following limb-threatening lower extremity trauma. J Orthop Trauma 23:1

    Article  PubMed  Google Scholar 

  31. Herrera FA, Hassanein AH, Potenza B et al (2010) Bilateral upper extremity vascular injury as a result of a high-voltage electrical burn. Ann Vasc Surg 24:825.e1

    Article  Google Scholar 

  32. Higgins TF, Klatt JB, Beals TC (2010) Lower Extremity Assessment Project (LEAP)–the best available evidence on limb-threatening lower extremity trauma. Orthop Clin North Am 41(2):233–239

    Article  PubMed  Google Scholar 

  33. Hoogendorn JM, van der Werken C (2001) Grade III open tibial fractures: functional outcome and quality of life in amputees versus patients with successful reconstrauction. Injury 32:329–334

    Article  Google Scholar 

  34. Howe HR Jr, Poole GV Jr, Hansen KJ, Clark T, Plonk GW, Koman LA, Penell TC (1987) Salvage of lower extremities following combined orthopedic and vasculöar trauma. A predictive salvage index. Am Surg 53:205–208

    PubMed  Google Scholar 

  35. Jens S, Kerstens MK, Legemate DA et al (2013) Diagnostic performance of computed tomography angiography in peripheral arterial injury due to trauma: a systematic review and meta-analysis. Eur J Vasc Endovasc Surg 46:329

    Article  CAS  PubMed  Google Scholar 

  36. Johansen K, Daines M, Howey T et al (1990) Objective criteria accurately predict amputation following lower extremity trauma. J Trauma 30:568

    Article  CAS  PubMed  Google Scholar 

  37. Johnson BA, Carmack D, Neary M et al (2005) Operation Iraqi Freedom: the Landstuhl Regional Medical Center experience. J Foot Ankle Surg 44:177

    Article  PubMed  Google Scholar 

  38. Kragh JF Jr, Walters TJ, Baer DG et al (2009) Survival with emergency tourniquet use to stop bleeding in major limb trauma. Ann Surg 249:1

    Article  PubMed  Google Scholar 

  39. Lynch K, Johansen K (1991) Can Doppler pressure measurement replace „exclusion“ arteriography in the diagnosis of occult extremity arterial trauma? Ann Surg 214:737

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  40. Ly TV, Travison TG, Castillo RC, Bosse MJ, MacKenzie EJ, the LEAP Study Group (2008) Abilitiy of lower-extremity injury severity scores to predict functional outcome after limb salvage. J Bone Joint Surg (Am) 90:1738–1743

    Article  Google Scholar 

  41. MacKenzie EJ, Fowler CJ (2008) Epidemiology. In: Feliciano DV, Mattox KL, Moore EE (Hrsg) Trauma, 6. Aufl. McGraw-Hill Medical, New York, S 25

    Google Scholar 

  42. Meisinger C, Wildner M, Stieber J, Heier M, Sangha O, Döring A (2002) Epidemiologie der Extremitätenfrakturen. Orthopäde 31:92–99

    Article  CAS  PubMed  Google Scholar 

  43. Meling T, Harboe K, Søreide K (2009) Incidence of traumatic long-bone fractures requiring in-hospital management: a prospective age- and gender-specific analysis of 4890 fractures. Injury 40:1212

    Article  PubMed  Google Scholar 

  44. Melvin JS, Dombroski DG, Torbert JT et al (2010) Open tibial shaft fractures: i. Evaluation and initial wound management. J Am Acad Orthop Surg 18:10

    Article  PubMed  Google Scholar 

  45. Menakuru SR, BEhera A, Jindal R, Kaman L, Doley R, VEnkatesan R (2005) Extremity vascular trauma in civilian population:a seven-year review from North India. Injury 36:400–406

    Article  PubMed  Google Scholar 

  46. Mills WJ, Barei DP, McNair P (2004) The value of the ankle-brachial index for diagnosing arterial injury after knee dislocation: a prospective study. J Trauma 56:1261

    Article  PubMed  Google Scholar 

  47. de Mestral C, Sharma S, Haas B et al (2013) A contemporary analysis of the management of the mangled lower extremity. J Trauma Acute Care Surg 74:597

    Article  PubMed  Google Scholar 

  48. McNamara MG, Heckamn JD, Corley EG (1994) Severe open fractures of the lower extremity: a retrospective evaluation of the Mangled Extremity Severity Score. J Orthop Trauma 8:81–87

    Article  CAS  PubMed  Google Scholar 

  49. Nance ML (2012) National Trauma Data Bank Annual Report. http://www.facs.org/trauma/ntdb/pdf/ntdb-annual-report-2012.pdf. Zugegriffen: 22. Okt. 2013

  50. Nickerson TP, Zielinski MD, Jenkins DH, Schiller HJ (2014) The Mayo Clinic experience with Morel-Lavallée lesions: establishment of a practice management guideline. J Trauma Acute Care Surg 76:493

    Article  PubMed  Google Scholar 

  51. Okike K, Bhattacharyya T (2006) Trends in the management of open fractures. A critical analysis. J Bone Joint Surg Am 88:2739

    Article  PubMed  Google Scholar 

  52. Orthopaedic Trauma Association (2010) Open Fracture Study Group. A new classification scheme for open fractures. J Orthop Trauma 24:457

    Google Scholar 

  53. Owens BD, Kragh JF Jr, Wenke JC et al (2008) Combat wounds in operation Iraqi Freedom and operation Enduring Freedom. J Trauma 64:295

    Article  PubMed  Google Scholar 

  54. Owens BD, Kragh JF Jr, Macaitis J et al (2007) Characterization of extremity wounds in Operation Iraqi Freedom and Operation Enduring Freedom. J Orthop Trauma 21:254

    Article  PubMed  Google Scholar 

  55. Patterson BM, Agel J, Swiontkowski MF et al (2007) Knee dislocations with vascular injury: outcomes in the Lower Extremity Assessment Project (LEAP) Study. J Trauma 63:855

    Article  PubMed  Google Scholar 

  56. Perkins ZB, Yet B, Glasgow S et al (2015) Meta-analysis of prognostic factors for amputation following surgical repair of lower extremity vascular trauma. Br J Surg 102:436–450

    Article  CAS  PubMed  Google Scholar 

  57. Peterson SL, Lehman TP (2008) Upper extremity injury. In: Feliciano DV, Mattox KL, Moore EE (Hrsg) Trauma, 6. Aufl. McGraw-Hill Medical, New York, S 871

    Google Scholar 

  58. Prasarn ML, HElfet DL, Kloen P (2012) Management of the mangled extremity. Strat Traum Limb Recon 7:57–66

    Article  Google Scholar 

  59. Propper BW, Alley JB, Gifford SM et al (2009) Endovascular treatment of a blunt aortic injury in Iraq: extension of innovative endovascular capabilities to the modern battlefield. Ann Vasc Surg 23:687.e19

    Article  Google Scholar 

  60. Rajasekram S, Naresh Babu J, Dheenadhayalan J, Shetty AP, Sundarajan SR, Kumar M, Rjasabapathy S (2006) A score for predicting salvage and outcome in Gustilo taype IIIa and type IIIb open tibial fractures. J Bone Joint Surg (Br) 88B:1351–1360

    Article  Google Scholar 

  61. Ravindra KV, Buell JF, Kaufman CL et al (2008) Hand transplantation in the United States: experience with 3 patients. Surgery 144:638

    Article  PubMed  Google Scholar 

  62. Rozycki GS, Tremblay LN, Feliciano DV, McClelland WB (2003) Blunt vascular trauma in the extremity: diagnosis, management, and outcome. J Trauma 55:814

    Article  PubMed  Google Scholar 

  63. Russell WL, SAilors DM, Whittle TB, Fisher DF Jr, Burns RP (1991) Limb salvage versus traumatic amputation. A decisison based on a seven part predictive index. Ann Surg 213:473–481

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  64. Sapega AA, Heppenstall RB, Sokolow DP et al (1988) The bioenergetics of preservation of limbs before replantation. The rationale for intermediate hypothermia. J Bone Joint Surg Am 70:1500

    CAS  PubMed  Google Scholar 

  65. Scalea TM, DuBose J, Moore EE, West M, Moore FA, McIntyre R, Cocanour C, Davis J, Ochsner MG, Feliciano D (2012) Western Trauma Assocication critical decisisons in trauma: management of the mangled extremity. J Trauma 72:86–93

    Google Scholar 

  66. Schlickewei W, Kuner EH, Mullaji AB, Götze B (1992) Upper and lower limb fractures with concomitant arterial injury. J Bone Joint Surg Br 74:181

    CAS  PubMed  Google Scholar 

  67. Seamon MJ, Smoger D, Torres DM et al (2009) A prospective validation of a current practice: the detection of extremity vascular injury with CT angiography. J Trauma 67:238

    Article  PubMed  Google Scholar 

  68. Smith JJ, Agel J, Swiontkowski MF, Castillo R, MacKenzie E, Kellam JF and the LEAP Study Group (2005) Functional outcome of bilateral limb threatening: lower extremnity injuries at two years postinjury. J Orthop trauma 19:249–253

    Article  PubMed  Google Scholar 

  69. Soto JA, Múnera F, Cardoso N et al (1999) Diagnostic performance of helical CT angiography in trauma to large arteries of the extremities. J Comput Assist Tomogr 23:188

    Article  CAS  PubMed  Google Scholar 

  70. Soto JA, Múnera F, Morales C et al (2001) Focal arterial injuries of the proximal extremities: helical CT arteriography as the initial method of diagnosis. Radiology 218:188

    Article  CAS  PubMed  Google Scholar 

  71. Swan KG Jr, Wright DS, Barbagiovanni SS et al (2009) Tourniquets revisited. J Trauma 66:672

    Article  PubMed  Google Scholar 

  72. Walters TJ, Wenke JC, Kauvar DS et al (2005) Effectiveness of self-applied tourniquets in human volunteers. Prehosp Emerg Care 9:416

    Article  PubMed  Google Scholar 

  73. Win TS, Henderson J (2014) Management of traumatic amputations of the upper limb. BMJ 348:g255

    Article  PubMed  Google Scholar 

  74. Wei FC, Chang YL, Chen HC, Chuang CC (1988) Three successful digital replantations in a patient after 84, 86, and 94 hours of cold ischemia time. Plast Reconstr Surg 82:346

    Article  CAS  PubMed  Google Scholar 

  75. White JM, Stannard A, Burkhardt GE et al (2011) The epidemiology of vascular injury in the wars in Iraq and Afghanistan. Ann Surg 253:1184

    Article  PubMed  Google Scholar 

  76. White PW, Gillespie DL, Feurstein I et al (2010) Sixty-four slice multidetector computed tomographic angiography in the evaluation of vascular trauma. J Trauma 68:96

    Article  PubMed  Google Scholar 

  77. Uyeda JW, Anderson SW, Sakai O, Soto JA (2010) CT angiography in trauma. Radiol Clin North Am 48:423

    Article  PubMed  Google Scholar 

  78. Yan H, Gao W, Li Z et al (2013) The management of degloving injury of lower extremities: technical refinement and classification. J Trauma Acute Care Surg 74:604

    Article  PubMed  Google Scholar 

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  1. Klinik für Unfallchirurgie und Orthopädie, Unfallkrankenhaus Berlin, Warenerstr. 7, 12683, Berlin, Deutschland

    J. Seifert, M. Frank & A. Ekkernkamp

  2. Zentrum für Orthopädie, Unfallchirurgie und Rehabilitative Medizin, Klinik und Poliklinik für Unfall-, Wiederherstellungschirurgie und Rehabilitative Medizin, Universitätsmedizin Greifswald, Ferdinand-Sauerbruch-Straße, 17475, Greifswald, Deutschland

    J. Seifert, D. Gümbel, M. Frank & A. Ekkernkamp

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Seifert, J., Gümbel, D., Frank, M. et al. Management und Outcome schwerster Extremitätenverletzungen. Trauma Berufskrankh 18, 7–15 (2016). https://doi.org/10.1007/s10039-016-0120-2

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