Phasenabgestimmtes Behandlungskonzept ausgedehnter Defektverletzungen an den Extremitäten im Rahmen des Polytraumamanagements

Abstract

Polytrauma is a term describing the condition of a person who has been simultaneously subjected to multiple traumatic injuries to at least two different areas of the body. The injuries are life threatening individually or in combination, e.g. a serious head injury in addition to a tension pneumothorax. It is defined via an Injury Severity Score (ISS) of at least 16 points.Adequate initial treatment of severely injured patients is significantly affected by the prediction or the knowledge of the post-traumatic course. Under pathophysiological aspects we distinguish between four different phases in polytrauma management:The surgical strategy should respect the phase-like post-traumatic course. We distinguish 4 phases: lifesaving immediate surgery, urgent primary interventions, secondary and tertiary interventions.After the acute care (“day 1-surgery”) there are 2 time windows where plastic surgery for reconstruction of extensive soft tissue defects can be performed. First, this is the period between the 5 and 10 posttraumatic day (“window of opportunity”). Here, after definitive fracture stabilization, a remaining soft tissue defect can be covered with split thickness skin graft or a local rotation flap. Another possibility for soft tissue reconstruction opens up after the period of immunosuppression (about 11 to 21 days after injury).In many multiply injured patients, primary closure of soft tissue injuries is critical. The relative hypoxia of tissues may lead to impairment and delayed wound healing. In addition, there is an increased risk of infection.For small soft-tissue injuries, we recommend a secondary wound closure after temporary covering the wound with artificial skin or skin substitutes until the swelling goes down.For medium soft tissue defects, a secondary closure is often achieved by mobilizing the surrounding soft tissues.In extensive soft tissue defects which are associated with considerable periosteal damage, soft tissue covering requires excellent perfusion. The defect coverage should be performed within 72 hours after the trauma. Otherwise there is a risk of further damage to this extremity.Large post-traumatic soft tissue defects are a challenge for the surgeon and require a well-defined therapeutic strategy. The overall concept of soft tissue coverage depends on the extent of exposed bone, tendons and nerves. An absolute prerequisite for wound closure is to completely cover the implants with vital and well-vascularized soft tissue. To obtain satisfactory results, early communication and cooperation between orthopaedic surgeons and plastic surgeons is recommend.In highly open fractures with extensive soft tissue defects (Group IIIb and IIIc) one must consider the possibility of early amputation, although the primary goal is to save the limbs. Long-term hospitalization has significant social and economic implications for the patient. The “mangled extremity severity score” (MESS) is an established decision-making aid.