Unfallchirurgie (Heidelberg, Germany)最新文献

Background: As part of the evaluation of a virtual multidisciplinary expert board to improve the treatment of trauma to the lower extremities (project EXPERT), work-related aspects are examined in addition to medical and economic outcomes. Initial results of a survey of employees involved in EXPERT are presented here.

Material and methods: Clinical staff worked on an online questionnaire on the topics of workload, work commitment, work-related resources and technical readiness. Work-related resources are physical, social and organizational aspects for overcoming work demands, such as peer support, feedback, opportunities to learn and meaningfulness of work. Factors that have a significant effect on work commitment and willingness to work were recorded.

Results: At the beginning of the project, the work commitment was very high, although the individual workload was also high. When individual stress was high, the willingness to use technology increased if sufficient work-related resources were available. Nonmedical staff showed a high willingness to use technology, especially with limited resources. With high team-related stress, e.g. due to conflicts and only a few resources, the willingness to use technology was particularly low.

Discussion: Diverse work-related resources not only strengthen work commitment but also the acceptance of digital innovations. In the case of high individual stress, employees, especially members of the nonmedical professions, perceived the use of technology as helpful. The prerequisite for this is that the cooperation in the team works.

The management of shaft fractures of the upper extremities is an integral part of trauma surgery in the clinical routine. While sport-associated injuries predominate in young adults, the incidence of osteoporotic fractures greatly increases in older patients. Despite established treatment strategies, complications such as wound healing disorders, infections, neurovascular injuries, malalignment, pseudarthrosis and implant failure are frequent. An effective complication management requires detailed knowledge of the morphological features of fractures, individual risk factors and differentiated revision strategies. With the presentation of two clinical cases, we aim to highlight the necessity of individualized treatment concepts. Due to the increasing number of war casualties transferred for secondary treatment to Central Europe, the likelihood of encountering unfamiliar injury patterns, such as blast or gunshot wounds, is rising. This development presents new challenges in daily clinical practice. Physiotherapeutic and occupational therapy support play a central role in achieving favorable functional outcomes following revision surgery for diaphyseal fractures of the upper extremities. In geriatric care, orthogeriatric concepts have significantly decreased mortality and improved mobilization as well as self-sufficiency among older patients. Managing patient expectations and providing close supervision throughout the rehabilitation process are decisive factors for successful recovery.

Forearm shaft fractures are the most common fractures of the upper extremity in young adults. By definition, these fractures are diaphyseal fractures; however, due to the complex functional unity formed by the forearm shaft during motion both bone forearm fractures are treated as intra-articular fractures [1, 3]. This is why the gold standard of treatment in adults is osteosynthesis. The aim of the surgical intervention is the anatomical reduction with exact reconstruction of length, shaft axis and rotation. This particularly concerns Monteggia and Galeazzi fractures where the adjacent joint needs to be addressed and/or the joint must be fixated to gain a precise joint position [2, 9]. Instability of the interosseous membrane must also be kept in mind, which is classically accompanied by comminuted radial head fractures (Essex-Lopresti injury) but can also occur with shaft fractures after complex and massive trauma [9, 10]. Complications with these three types of injury occur when the joint involvement is overlooked and hence must be specifically searched for [9]. A typical complication after forearm fractures is the formation of pseudarthrosis [4, 5, 11, 12]. For prevention, a procedure must be selected that preserves the soft tissue and periosteum as much as possible; locking plates enable a stable fixation without compression of the periosteum [1, 4]. Nerve damage can occur either posttraumatically or after surgical intervention and is frequently seen with very proximal forearm fractures [3, 5, 12]. Refractures are rarely seen with inlaying implants but commonly occur after implant removal, which is why it should be done 24 months postoperatively at the earliest [2, 5, 13]. With concomitant fractures of the radius and ulna there is a high risk of synostosis which often leads to considerable impairment of movement [5, 11, 12]. In some cases, especially with traumatic brain injury, a synostosis cannot be avoided even with preventative measures and subsequently must be resected [5]. Furthermore, insufficient osteosynthesis or implant failure can lead to axial malalignment and subsequently to limited rotational mobility [5]. The renewed open anatomical reduction with compression osteosynthesis and secure plate fixation, fixated with three screws proximal and distal to the fracture, enables an exact reconstruction of the bone shape as well as the avoidance of secondary malalignment through implant loosening [1, 5].

Shaft fractures in children and adolescents differ from those of adulthood in terms of the fracture pattern and treatment. With respect to the procedure, humeral shaft fractures must be differentiated from forearm shaft fractures. Almost no axial deviation can be tolerated on the forearm shaft, even at a young age as this could lead to functional restrictions in the rotation of the forearm. For these reasons, closed reduction and elastic stable intramedullary nailing (ESIN) nowadays represents the gold standard for dislocated or unstable fractures. A special type is the greenstick fracture of the forearm shaft where there is also a risk of refracture due to the partial healing disorder. In the region of the humeral shaft, residual axial deviations play a role mainly with respect to the cosmetic results. Substantial functional limitations are not to be expected. Many of these fractures can be treated conservatively. In cases of instability or unacceptable dislocation, ESIN osteosynthesis is the first choice as a minimally invasive procedure for surgical treatment.

Background: Humeral shaft fractures occur with an incidence of approximately 12-25 per 100,000 per year and exhibit two age peaks, young patients following high-energy trauma and older patients with low-energy trauma.

Treatment: Principally, conservative treatment is a viable option, which requires high patient compliance but shows good healing rates in appropriate cases, particularly for fractures of the middle third of the shaft. Compared to surgical treatment there is a slightly increased rate of pseudarthrosis. In the case of surgical treatment, both plate osteosynthesis and intramedullary nailing show good results.

Radial nerve injury: A distinction must be made between primary radial nerve injury, which occurs immediately after trauma and generally has good spontaneous recovery rates, and secondary radial nerve injury, which is a consequence of the initiated treatment. In this case, careful consideration should be given to the potential need for a surgical intervention.

Conclusion: Overall, both conservative and surgical treatment approaches lead to good functional outcomes in appropriately selected patients. The choice of treatment should be made individually, considering the patient's age, fracture complexity, comorbidities and expected patient compliance.

The treatment of polytraumatized patients is challenging. Intensive efforts and interdisciplinary teamwork have improved survival rates of severely injured patients over the last decades. High quality guideline recommendations focusing on the prehospital setting, emergency room management and also the initial surgical phase have been published and are frequently updated. The current manuscript is part of new guidelines on an S3 level that focuses on treatment of polytraumatized patients who were transferred to the intensive care unit after initial emergency treatment. These patients have special needs, especially with respect to monitoring, pain management, ventilation strategy, nutrition etc. and most often require definitive surgical stabilization of injuries to the thorax, abdomen, pelvis and extremities. This article summarizes the current literature and gives recommendations with respect to early definitive treatment of patients with multiple trauma and particularly with a view to the best possible timing of the definitive treatment.

Background: With the 2023 revision of the German S3 guideline "Polytrauma/severely injured patient care" the criteria for trauma team activation (TTA) were revised. Accident mechanism-based criteria were largely eliminated. The impact of these changes on emergency department (ED) management, over- and undertriage following traffic accidents, and hospital length of stay has not yet been systematically evaluated.

Objective: The aim of this study was to assess the effects of the guideline update on patient treatment in the emergency department of a level I trauma center.

Methods: In a prospective, single-center observational study, all patients presenting after motor vehicle accidents were recorded over a 2-year period (pre- vs. postguideline update). Primary endpoints were the frequency and appropriateness of TTA as well as the distribution of treatment locations. Secondary endpoint was hospital length of stay.

Results: A total of 1438 cases were analyzed. The number of red-triaged patients decreased significantly (257 vs. 157; p < 0.001). The overtriage rate among TTA patients declined (27.6% vs. 21%, p < 0.01) without a significant increase in undertriage. Mortality and hospital length of stay did not differ significantly between groups.

Conclusion: The revision of TTA criteria led to a marked reduction in trauma team activations while maintaining quality of care. No significant increase in undertriage was observed. The updated TTA criteria may support resource-efficient patient care without compromising safety.

Background: Embolization via interventional radiology (IR) plays a critical role in the management of trauma patients and is effective in controlling arterial hemorrhaging in the pelvis, retroperitoneum, and gastrointestinal tract.

Objective: To evaluate the role of IR in the management of traumatic arterial bleeding in the pelvic, retroperitoneal and gastrointestinal regions.

Material and methods: A comprehensive literature review was conducted to assess the current evidence regarding the indications, procedural techniques and results of embolization following trauma in the named regions.

Results: The decision to perform embolization is determined individually and interdisciplinary based on contrast-enhanced computed tomography (CT). In cases of arterial bleeding, embolization following pelvic trauma is a key pillar of treatment. Posttraumatic retroperitoneal renal embolization is indicated as the method of choice in cases of traumatic arterial bleeding without devascularization or fragmentation of the kidney. Although there is a lack of robust data and clear guidelines for embolization in traumatic gastrointestinal and other retroperitoneal hemorrhages, evidence from nontraumatic cases suggests a high therapeutic potential. The endovascular techniques used in trauma closely mirror those employed in nontraumatic vascular occlusion interventions in these regions.

Discussion: Targeted embolization effectively controls traumatic bleeding.

Distal fractures of the femur are becoming increasingly more important due to demographic changes and the increasing use of endoprosthetic treatment. The updated S2 guidelines on distal femoral fractures were developed by an interdisciplinary consensus and combine current evidence and clinically proven procedures for the treatment of these diverse fracture types. The main focus is on a differentiated fracture classification, patient-specific risk factors and the precise assessment of fracture morphology, soft tissue damage and general condition. Compared to conservative measures, surgical treatment has become established as the standard, with various osteosynthesis techniques being used, from plate and screw osteosynthesis to intramedullary nailing and distal femur replacement. The guidelines also consider perioperative measures, imaging techniques and rehabilitative strategies to prevent long-term complications. The following article illustrates the practical implementation of the guidelines based on clinical case studies and offers practical guidance.