Der Unfallchirurg
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In the management of multiply injured patients the question of the optimal time point for surgical treatment of individual injuries still remains open. Especially in severely injured patients with pelvic fractures, this decision differs between rapid surgical interventions in life-threatening situations or time-consuming reconstructive surgery. Besides the "early" operative treatment, i.e., within the first 24 h after trauma, the "late," i.e., definitive or secondary surgical fracture stabilization, exists. The following study represents a review of the current recommendations in the literature concerning the optimal time and fracture management of multiply injured patients with pelvic fracture. ⋯ Basically, the principles of trauma management of multiply injured patients with life-threatening hemorrhage from mechanically unstable pelvic fractures are divided into two main time periods. On the one hand, there is the emergency stabilization of the pelvic ring as the most important goal within the acute period to control the bleeding, at least with extraperitoneal tamponade if necessary. On the other hand, once the hemorrhaging has been stopped, the "late" and definitive internal fracture stabilization of the pelvis should be performed depending on the fracture pattern.
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In the management of patients with multiple injuries, the concept of damage control orthopedics (DCO) is still a matter of controversy. Thus, the clinical value of DCO remains unclear and should be evaluated on an evidence-based level by a review of the current literature. ⋯ The advocates of DCO claim that patients with multiple injuries including severe brain and chest injuries as well as those with an unstable cardiopulmonary or circulatory condition are at high risk of developing a severe systemic immuno-inflammatory reaction during early total fracture care. Therefore, they recommend primary minimally invasive external fracture stabilization in these patients to avoid additional surgical trauma and that definitive secondary fracture care should be performed after medical stabilization of the patient in intensive care.
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Operability is mainly determined by the interaction between the magnitude of an operation and the patient's tolerance for the procedure. A further factor is the benefit gained by performing the procedure versus the sequelae caused by its omission. ⋯ The pathophysiological consequences of accidental trauma show a phasic course with respect to the immunomodulatory response. An operative trauma inflicted by a secondary surgical intervention contributes an additional burden. Depending on the inflammatory phase during which this secondary hit is inflicted there may be a disturbance of homoeostasis that may even lead to multiple organ failure. Whether this happens can depend on type and magnitude of the surgical intervention. Minor operations result in smaller systemic effects and will be less critical with respect to operability.
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Review
[Operative strategies for hand injuries in multiple trauma. A systematic review of the literature].
Hand injuries are not life threatening but crucial in multiple trauma because of their long-term functional results. The goal of this systematic review was to derive recommendations for diagnostic and treatment procedures from a systematic review of the literature. ⋯ Hand injuries represent important lesions in multiple trauma. Due to the life-threatening situation they may be overlooked in the beginning of the treatment. Because of their long-term consequences for function and health-related quality of life, hand injuries require an early and accurate diagnosis and a differentiated treatment strategy.
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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 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.