Frakturversorgung des Schwerverletzten – Einfluss des Prinzips der “verletzungsadaptierten Behandlungsstrategie” (“damage control orthopaedic surgery”)

Zusammenfassung

Die Operationsindikationen auf dem Gebiet der Frakturstabilisierung bei Schwerverletzten haben sich in den letzten Jahrzehnten gewandelt.Der Beginn der standardisierten chirurgischen Behandlung in den frühen 1960er Jahren stellt den Wendepunkt in der Versorgung polytraumatisierter Patienten dar.Neue Erkenntnisse führten zu ständigen Veränderungen in der operativen Stabilisierung von Frakturen bei schwerverletzten Patienten. Es wurden immer wieder lebhafte Diskussionen entfacht,welche letztlich unser Verständnis der komplexen klinischen und biochemischen Veränderungen nach schweren Verletzungen beeinflussten. Im vorliegenden Beitrag ist eine Synopsis der verfügbaren Informationen dargestellt,welche die Grundlage für unsere gegenwärtige klinische Versorgungsstrategie bildet.

Abstract

There have been substantial changes in the management of multiply injured patients over the last decades.In the 1950ies and 60ies, perioperative care was limited and the surgical techniques were not well developed. It was therefore discussed that a patient might be “too sick to operate” and the general recommendation was to postpone surgical care of the extremities,until a patient had stabilized. In addition this recommendation was maintained by fears of the “fat embolism syndrome”, which was considered to be directly related to fat and intramedullary contents released from the fracture site leading many to believe that early manipulation of the fracture was unsafe.The use of simple splintage clearly demonstrated the importance of skeletal stabilisation by reducing the effect of any continuing injury and this positive effect of skeletal stabilistion became more obvious with the implementation of standardized techniques of osteosynthesis.In the 1970's, pioneer studies appeared in the literature reporting that immediate stabilisation of femur fractures drastically reduced problems of traumatic pulmonary failure and post-operative care when compared to traditional non-operative fracture management.Thereafter, immediate and complete definitive operative care of all fractures has been said to represent the optimal treatment for lthe patient with multiple orthopaedic injuries and the benefits of this approach have been demonstrated in numerous studies within the last two decades.However,exceptions have been discussed in the past few years, where the principle of early total care may not be beneficial (head and chest trauma, high ISS predisposing to posttraumatic complications, borderline patients)).In high risk, borderline patients, the surgical burden was demonstrated to increase the risk of postoperative complications.For these patients, the concept of initial temporary fixation and secondary conversion to a definitive procedure has recently been advocated, and the term “damage control orthopaedic surgery” was coined.Within recent years, an increased consensus has occurred across the coutries and the oceans in regards to the acceptance of the concept of damage control.This manuscript documents the pathogenetic back grounds and the clinical results leading to a change in the management of orthopaedic injuries towards damage control.