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Verletzungen des Fußes beim polytraumatisierten Patienten

Foot injuries in the polytraumatized patient

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Zusammenfassung

Fußverletzungen bestimmen beim Polytrauma nicht das Überleben, beeinflussen aber entscheidend die spätere Lebensqualität der Patienten. Initial werden geschlossene Frakturen und Luxationen am Fuß beim Polytrauma überproportional häufig übersehen oder fehlinterpretiert, was im Langzeitverlauf bei den überlebenden Patienten regelmäßig zu schweren funktionellen Defiziten führt. Eine regelmäßige klinische Untersuchung des bewusstlosen Patienten und eine rasche, subtile radiologische Diagnostik nach Stabilisierung der Vitalfunktionen sind daher zu fordern.

Die Notfallindikation zur Operation besteht auch beim Polytrauma bei offenen Verletzungen, Inkarzeration der Weichteile, manifestem Kompartmentsyndrom sowie Gefäß- und Nervenverletzungen. Der Entscheid zum Extremitätenerhalt beim komplexen Fußtrauma muss individuell entsprechend dem Gesamtzustand des Patienten und dem lokalen Trauma gestellt werden, wobei das Prinzip „life before limb“ oberste Priorität besitzt. Die notfallmäßige Reposition von Luxationsfrakturen des Talus, Kalkaneus, Chopart- und Lisfranc-Gelenks über direkte Zugänge und temporäre Transfixation mit Kirschner-Drähten ist im 1. Schritt prinizpiell indiziert. Die zusätzliche Anlage eines Fixateur externe erleichtert die Wundpflege und verhindert Weichteilkontrakturen bis zur definitiven Versorgung. Eine frühzeitige Weichteildeckung ist zur Infektprophylaxe immer anzustreben.

Abstract

Foot injuries in polytraumatized patients are not critical for survival but for the later quality of life. Closed fractures or dislocations of the foot are frequently overlooked or misinterpreted in association with polytrauma, which leads to severe functional impairment in those patients who survive. Repeated clinical examinations and early radiographic examinations are essential in the unconscious patient after resuscitation.

Emergent indications for surgery even in the presence of multiple injuries are open injuries, incarcerated soft tissues, manifest compartment syndrome of the foot, and neurovascular injury. The decision on limb salvage or amputation has to be individualized with respect to the patient’s overall condition and the severity of local trauma to the foot. The “life before limb” principle has to be respected. Emergent reduction of fracture dislocations of the talus, calcaneus, Chopart’s and Lisfranc’s joints via direct approaches and temporary transfixation with K-wires should be attempted in a first step whenever possible. Additional external fixation facilitates wound care and prevents soft tissue contractions until definite internal fixation becomes feasible. Early soft tissue coverage is always sought in order to avoid infection.

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Literatur

  1. Aktuglu K, Aydogan U (2002) The functional outcome of displaced intra-articular calcaneal fractures: a comparison between isolated cases and polytrauma patients. Foot Ankle Int 23: 314-318

    PubMed  Google Scholar 

  2. Benirschke SK, Sangeorzan BJ (1993) Extensive intraarticular fractures of the foot. Surgical management of calcaneal fractures. Clin Orthop 290: 128–134

    Google Scholar 

  3. Brenner P, Rammelt S, Gavlik JM, Zwipp H (2001) Early soft tissue coverage after complex foot trauma. World J Surg 25: 603–609

    Article  PubMed  CAS  Google Scholar 

  4. Canale ST, Kelly FB Jr (1978) Fractures of the neck of the talus. J Bone Joint Surg Am 60: 143–156

    CAS  PubMed  Google Scholar 

  5. Chapman MW, Olson SA (1996) The treatment of open fractures. In: Rockwood CA, Green DP, Bucholz RW eds) Fractures in adults. Lippincott, Philadelphia, p 347

  6. Dewar FP, Evans DC (1968) Occult fracture-subluxation of the midtarsal joint. J Bone Joint Surg Br 50: 386–388

    PubMed  CAS  Google Scholar 

  7. Grob D, Simpson LA, Weber BG, Bray T (1985) Operative treatment of displaced talus fractures. Clin Orthop 199: 88–96

    PubMed  Google Scholar 

  8. Haapamaki V, Kiuru M, Koskinen S (2004) Lisfranc fracture-dislocation in patients with multiple trauma: diagnosis with multidetector computed tomography. Foot Ankle Int 25: 614–619

    PubMed  Google Scholar 

  9. Hansen ST (2001) Salvage or amputation after complex foot and ankle trauma. Orthop Clin North Am 32: 181–186

    Article  PubMed  Google Scholar 

  10. Hawkins LG (1970) Fractures of the neck of the talus. J Bone Joint Surg Am 52: 991–1002

    PubMed  CAS  Google Scholar 

  11. Heckman JD, Champine M (1989) New techniques in the management of foot trauma. Clin Orthop 240: 105

    PubMed  Google Scholar 

  12. Heier KA, Infante AF, Walling AK, Sanders RW (2003) Open fractures of the calcaneus: soft-tissue injury determines outcome. J Bone Joint Surg Am 85: 2276–2282

    PubMed  Google Scholar 

  13. Hidalgo DA, Shaw WW (1986) Anatomical basis of plantar flap design. Plast Reconstr Surg 78: 627–636

    CAS  PubMed  Google Scholar 

  14. Horowitz JH, Nichter LS, Kenney JG et al. (1985) Lawnmower injuries in children. Lower extremity reconstruction. J Trauma 25: 1138

    PubMed  CAS  Google Scholar 

  15. Johansen K, Daines M, Howey T, Helfet D, Hansen ST (1990) Objective criteria accurately predict amputation following lower extremity trauma. J Trauma 30: 568–573

    PubMed  CAS  Google Scholar 

  16. Kotter A, Wieberneit J, Braun W, Ruter A (1997) Die Chopart-Luxation. Eine häufig unterschätzte Verletzung und ihre Folgen. Eine klinische Studie. Unfallchirurg 100: 737–741

    Article  PubMed  CAS  Google Scholar 

  17. Kremli MK (1996) Missed musculoskeletal injuries in a University Hospital in Riyadh: types of missed injuries and responsible factors. Injury 27: 503–506

    Article  PubMed  CAS  Google Scholar 

  18. Kuner EH, Lindenmaier HL (1983) Zur Behandlung der Talusfraktur. Kontrollstudie von 262 Behandlungsfällen. Unfallchirurgie 9: 35–40

    PubMed  CAS  Google Scholar 

  19. Levin LS, Nunley JA (1993) The management of soft tissue problems associated with calcaneal fractures. Clin Orthop 290: 151–160

    PubMed  Google Scholar 

  20. Lindvall E, Haidukewych G, DiPasquale T, Herscovici D Jr, Sanders R (2004) Open reduction and stable fixation of isolated, displaced talar neck and body fractures. J Bone Joint Surg Am 86: 2229–2234

    PubMed  Google Scholar 

  21. Main BJ, Jowett RL (1975) Injuries of the midtarsal joint. J Bone Joint Surg Br 57: 89–97

    PubMed  CAS  Google Scholar 

  22. Manoli A, Weber TG (1990) Fasciotomy of the foot: an anatomical study with special reference to release of the calcaneal compartment. Foot Ankle 10: 267–275

    PubMed  Google Scholar 

  23. Manoli A, Fakhouri AJ, Weber TG (1993) Concurrent compartment syndromes of the foot and leg. Foot Ankle 14: 339

    PubMed  Google Scholar 

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

    PubMed  CAS  Google Scholar 

  25. Menke H, Baumeister S, Erdmann D, Sauerbier M, Germann G (2000) Therapeutische Optionen zur Behandlung von Fersendefekten. Chirurg 71: 311–318

    Article  PubMed  CAS  Google Scholar 

  26. Metak G, Scherer MA, Dannohl C (1994) Übersehene Verletzungen des Stütz- und Bewegungsapparates beim Polytrauma — eine retrospective Studie. Zentralbl Chir 119: 88–94

    PubMed  CAS  Google Scholar 

  27. Mittlmeier T, Machler G, Lob G, Mutschler W, Bauer G, Vogl T (1991) Compartment syndrome of the foot after intraarticular calcaneal fracture. Clin Orthop 269: 241–248

    PubMed  Google Scholar 

  28. Mubarak SJ, Owen CA (1975) Compartmental syndrome and its relation to the crush syndrome: a spectrum of disease — a review of 11 cases of prolnged limb compression. Clin Orthop 113: 81–89

    Article  PubMed  Google Scholar 

  29. Musharrafieh R, Osmani O, Saghieh S, El-Hassan B, Atiyeh B (1999) Microvascular composite tissue transfer for the management of type IIIB and IIIC fractures of the distal leg and compound foot fractures. J Reconstr Microsurg 15: 501–507

    Article  PubMed  CAS  Google Scholar 

  30. Myerson MS, Fisher RT, Burgess AR, Kenzora JE (1986) Fracture dislocations of the tarsometatarsal joints: end results correlated with pathology and treatment. Foot Ankle 6: 225–242

    PubMed  CAS  Google Scholar 

  31. Myerson MS (1988) Experimental decompression of fascial compartments of the foot: the basis for fasciotomy in acute compartment syndromes. Foot Ankle 8: 308–314

    PubMed  CAS  Google Scholar 

  32. Myerson MS (1991) Management of compartment syndromes of the foot. Clin Orthop 271: 239

    PubMed  Google Scholar 

  33. Myerson MS (1999) Soft tissue trauma: acute and chronic management. In: Mann RA, Coughlin MJ (eds) Surgery of the foot and ankle, Vol. II. Mosby, St Louis, pp 1330–1372

  34. Rammelt S, Gavlik JM, Winkler J, Zwipp H (2002) Mittelfristige Behandlungsergebnisse nach zentralen Talusfrakturen. In: Siewert J, Hartel W (Hrsg) 119. Kongreß der Deutschen Gesellschaft für Chirurgie 2002. Springer, Berlin Heidelberg New York, pp 541–542

  35. Rammelt S, Grass R, Schikore H, Zwipp H (2002) Verletzungen des Chopart-Gelenks. Unfallchirurg 105: 371–385

    Article  PubMed  CAS  Google Scholar 

  36. Rammelt S, Barthel S, Biewener A, Gavlik JM, Zwipp H (2003) Calcaneusfrakturen. Offene Reposition und interne Stabilisierung. Zbl Chir 128: 517–528

    PubMed  CAS  Google Scholar 

  37. Rammelt S, Zwipp H (2004) Calcaneus fractures: facts, controversies and recent developments. Injury 35: 443–461

    Article  PubMed  Google Scholar 

  38. Rammelt S, Amlang M, Barthel S, Zwipp H (2004) Minimally-invasive treatment of calcaneal fractures Injury 35(Suppl 2): 55–63

  39. Rammelt S, Heineck J, Zwipp H (2004) Metatarsal fractures. Injury 35(Suppl 2): 77–86

    Article  Google Scholar 

  40. Randt T, Dahlen C, Schikore H, Zwipp H (1998) Luxationsfrakturen im Mittelfußbereich — Verletzungen des Chopart- und Lisfranc-Gelenkes. Zentralbl Chir 123: 1257–1266

    PubMed  CAS  Google Scholar 

  41. Reigstad A, Hetland KR (1994) Free flap coverage in the reconstruction of foot injury. Acta Orthop Scand 65: 103–106

    Article  PubMed  CAS  Google Scholar 

  42. Ross G, Cronin R, Hauzenblas J, Juliano P (1986) Plantar ecchymosis sign: a clinical aid to diagnosis of occult Lisfranc tarsometatarsal injuries. J Orthop Trauma 10: 119–122

    Article  Google Scholar 

  43. Sackett DL, Straus SW, Richardson WS, Rosenberg W, Haynes RB (2000) Evidence-based medicine: How to practice and teach EBM, 2nd edn. Churchill Livingstone, London

  44. Sanders R, Pappas J, Mast J, Helfet D (1992) The salvage of open grade IIIB ankle and talus fractures. J Orthop Trauma 6: 201–208

    Article  PubMed  CAS  Google Scholar 

  45. Sanders R (2000) Displaced intra-articular fractures of the calcaneus. J Bone Joint Surg Am 82: 225–250

    PubMed  CAS  Google Scholar 

  46. Sangeorzan BJ, Hansen ST (1989) Early and late posttraumatic foot reconstruction. Clin Orthop 243: 86–91

    PubMed  Google Scholar 

  47. Sangeorzan BJ, Benirschke SK, Mosca VEA (1989) Displaced intraarticular fractures of the tarsal navicular. J Bone Joint Surg Am 71: 1504–1510

    PubMed  CAS  Google Scholar 

  48. Saudan M, Peter R, Delmi M.(2002) Talar neck fracture: 9-year follow-up of 40 cases. Rev Chir Orthop Reparat Appar Mot 88: 168-176

    CAS  Google Scholar 

  49. Schulze W, Richter J, Russe O, Ingelfinger P, Muhr G (2002) Surgical treatment of talus fractures: a retrospective study of 80 cases followed for 1–15 years. Acta Orthop Scand 73: 344–351

    Article  PubMed  Google Scholar 

  50. Seiler H, Braun C, op den Winkel R, Zwank L (1986) Macro- and microreplantations of the lower leg and foot. Langenbecks Arch Chir 369: 625–627

    Article  PubMed  CAS  Google Scholar 

  51. Simpson AH, Deakin M, Latham JM (2001) Chronic osteomyelitis. The effect of the extent of surgical resection on infection-free survival. J Bone Joint Surg Br 83: 403–407

    Article  PubMed  CAS  Google Scholar 

  52. Stiegelmar R, McKee MD, Waddell JP, Schemitsch EH (2001) Outcome of foot injuries in multiply injured patients. Orthop Clin North Am 32: 193–204

    Article  PubMed  CAS  Google Scholar 

  53. Swiontkowski MF (1996) The multiply-injured patient with musculoskeletal injuries. In: Rockwood CA, Green DP, Bucholz RW (eds) Fractures in adults. Lippincott, Philadelphia, pp 130–157

  54. Szyszkowitz R, Reschauer R, Seggl W (1985) Eighty-five talus fractures treated by ORIF with five to eight years of follow-up study of 69 patients. Clin Orthop 199: 97–107

    PubMed  Google Scholar 

  55. Tennent T, Calder P, Salisbury R et al. (2001) The operative management of displaced intra-articular fractures of the calcaneum: a two-centre study using a defined protocol. Injury 32: 491–496

    Article  PubMed  CAS  Google Scholar 

  56. Tran T, Thordarson D (2002) Functional outcome of multiply injured patients with associated foot injury. Foot Ankle Int 23: 340–343

    PubMed  MathSciNet  Google Scholar 

  57. Tscherne H, Oestern HJ (1982) Eine neue Klassifikation des Weichteilschadens bei geschlossenen und offenen Frakturen. Unfallheilkunde 85: 111–115

    PubMed  CAS  Google Scholar 

  58. Tscherne H (1986) Management der Verletzungen am distalen Unterschenkel und Fuß. Langenbecks Arch Chir 369: 539–542

    Article  PubMed  CAS  Google Scholar 

  59. Tscherne H, Regel G, Sturm JA, Friedl HP (1987) Schweregrad und Prioritäten bei Mehrfachverletzungen. Chirurg 58: 631–640

    PubMed  CAS  Google Scholar 

  60. Turchin DC, Schemitsch EH, McKee MD, Waddell JP (1999) Do foot injuries significantly affect the functional outcome of multiply injured patients? J Orthop Trauma 13: 1–4

    Article  PubMed  CAS  Google Scholar 

  61. Whitesides TEJ, Haney TC, Morimoto K (1975) Tissue pressure measurements as a determinant for the need of fasciotomy. Clin Orthop 113: 43–51

    Article  PubMed  Google Scholar 

  62. Vallier HA, Nork SE, Benirschke SK, Sangeorzan BJ (2003) Surgical treatment of talar body fractures. J Bone Joint Surg Am 85: 1716–1724

    PubMed  Google Scholar 

  63. Vallier HA, Nork SE, Barei DP, Benirschke SK, Sangeorzan BJ (2004) Talar neck fractures: results and outcomes. J Bone Joint Surg Am 86: 1616–1624

    PubMed  Google Scholar 

  64. Ziv I, Zeligowski A, Mosheiff R, Lowe J, Wexler MR, Segal D (1988) Split-thickness skin excision in severe open fractures. J Bone Joint Surg Br 70: 23–26

    PubMed  CAS  Google Scholar 

  65. Zwipp H, Tscherne H, Thermann H, Weber T (1993) Osteosynthesis of displaced intraarticular fractures of the calcaneus. Results in 123 cases. Clin Orthop 290: 76–86

    PubMed  Google Scholar 

  66. Zwipp H (1994) Chirurgie des Fußes. Springer, Wien New York

  67. Zwipp H, Dahlen C, Randt T, Gavlik JM (1997) Komplextrauma des Fußes. Orthopäde 26: 1046–1056

    CAS  PubMed  Google Scholar 

  68. Zwipp H, Rammelt S (2002) Frakturen und Luxationen. In: Wirth CJ, Zichner L (Hrsg) Orthopädie und Orthopädische Chirurgie, Bd. 8. Thieme, Stuttgart New York, S 531–618

  69. Zwipp H, Rammelt S, Barthel S (2003) Management offener Calcaneusfrakturen. Trauma Berufskrankh 5(Suppl 1): 47–51

    Article  Google Scholar 

  70. Zwipp H, Rammelt S, Barthel S (2004) Open reduction and internal fixation (ORIF) of calcaneal fractures. Injury 35(Suppl 2): 46–54

    Article  Google Scholar 

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  1. Klinik und Poliklinik für Unfall- und Wiederherstellungschirurgie, Universitätsklinikum „Carl Gustav Carus“, TU, Dresden

    S. Rammelt, A. Biewener, R. Grass & H. Zwipp

  2. Klinik und Poliklinik für Unfall- und Wiederherstellungschirurgie, Universitätsklinikum „Carl Gustav Carus“, TU, Fetscherstraße 74, 01307, Dresden

    S. Rammelt

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  1. S. Rammelt
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Rammelt, S., Biewener, A., Grass, R. et al. Verletzungen des Fußes beim polytraumatisierten Patienten. Unfallchirurg 108, 858–865 (2005). https://doi.org/10.1007/s00113-005-0993-1

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