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Versorgungsstrategien in der ersten operativen Phase nach Verletzung langer Röhrenknochen der unteren Extremität beim Polytrauma

Eine systematische Literaturübersicht

Management strategies in the first operative phase after long-bone injury of the lower extremity in multiple-injured patients

A systematic literature review

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Zusammenfassung

Fragestellung

Verletzungen der unteren Extremität haben einen wesentlichen Anteil im Verletzungsmuster polytraumatisierter Patienten. Das Ziel dieser systematischen Literaturanalyse ist es, einen Überblick über die Evidenzlevel (EL) unterschiedlicher Versorgungsstrategien von Frakturen der unteren Extremität beim Polytrauma in der ersten operativen Phase zu erstellen und hieraus entweder (bei genügender Evidenz) klinische Behandlungskorridore abzuleiten oder aber (bei ungenügender Evidenz) die Notwendigkeit wissenschaftlicher Überprüfung zu dokumentieren.

Methodik

Klinische Studien wurden über systematische Suchen (Medline, Cochrane und Handsuchen) und Klassifikation nach Evidenzlevel (EL1–5 nach Oxforder Schema) zusammengetragen.

Ergebnisse

Die Notwendigkeit einer primär- vs. sekundär-definitiven Osteosynthese von Schaftfrakturen des Femurs/der Tibia beim Polytrauma ist derzeit noch nicht hinreichend geklärt. Das Operationsverfahren der Wahl zur definitiven Versorgung einer Femurschaftfraktur ist die Marknagelung. Der Stellenwert der Stabilisierung von proximalen und distalen Femur- sowie Tibiafrakturen beruht größtenteils auf Expertenmeinung. Nach der Literatur ist eine perioperative Antibiotikaprophylaxe bei der operativen Frakturversorgung indiziert.

Schlussfolgerungen

Zu Versorgungsstrategien in der ersten operativen Phase nach Verletzungen langer Röhrenknochen der unteren Extremität beim Polytrauma liegen eine Vielzahl vergleichender Untersuchungen (EL2) vor, randomisierte Studien existieren jedoch wenige. Anhand der Datenlage ist eine wissenschaftlich begründete Behandlung dieser Patienten in weiten Bereichen möglich.

Abstract

Objective

Lower extremity injuries make up a substantial proportion of the injuries in multiply injured patients. The aim of this systematic literature analysis was to give an overview of the levels of evidence for different management strategies in the first operative phase after long-bone injuries of the lower extremity in multiply injured patients to enable, in the presence of adequate evidence, the development of clinical management corridors or, if the evidence was found to be inadequate, to document the necessity for scientific proof.

Methods

Clinical trials were systematically collected (Medline, Cochrane and hand searches) and classified into evidence levels (EL 1 to 5 according to the Oxford system).

Results

The necessity for primary or secondary definitive osteosynthesis of femur/tibia shaft fractures is still a matter of discussion. Intramedullary nailing is the preferred operative procedure for definitive treatment of femur shaft fractures. Stabilization of proximal and distal femur and tibia fractures is predominantly based on expert opinion. According to the literature, perioperative antibiotic prophylaxis is essential in fracture treatment.

Conclusion

Numerous comparative studies (EL 2) dealing with management strategies in the first operative phase after long-bone injuries of the lower extremity in multiply injured patients are available, but there are only a few randomized studies. Based on the available data, it is possible to develop a rational therapy for this patient population.

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Danksagung

Die Autoren bedanken sich bei Frau Dr. V. Keck und den Herren Dr. S. Grote, D. Schmischke, Dr. C. Simanski, Dr. T. Tjardes und Dr. N. Yücel für die Mithilfe in Teilbereichen der Literaturanalyse.

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  1. Klinik für Unfallchirurgie, Lehrstuhl der Universität Witten/Herdecke, Klinikum Köln-Merheim

    D. Rixen & B. Bouillon

  2. Biochemische und Experimentelle Abteilung, Medizinische Fakultät, Universität zu Köln

    S. Sauerland

  3. Klinik für Unfall- und Wiederherstellungschirurgie, Allgemeines Krankenhaus, Celle

    H.-J. Oestern

  4. Klinik für Unfallchirurgie, Klinikum Köln-Merheim, Lehrstuhl der Universität Witten/Herdecke, Ostmerheimerstraße 200, 51109, Köln

    D. Rixen

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Rixen, D., Sauerland, S., Oestern, HJ. et al. Versorgungsstrategien in der ersten operativen Phase nach Verletzung langer Röhrenknochen der unteren Extremität beim Polytrauma. Unfallchirurg 108, 829–842 (2005). https://doi.org/10.1007/s00113-005-1012-2

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