Sprunggelenkfraktur beim älteren Patienten

Was sollten wir anders machen?

Ankle fractures in older patients

What should we do differently?

An Erratum to this article was published on 19 February 2021

This article has been updated

Zusammenfassung

Sprunggelenkfrakturen beim älteren Patienten gehören aufgrund der demografischen Entwicklung zum unfallchirurgischen Alltag. Aufgrund von Begleiterkrankungen wie Diabetes mellitus, reduzierter Knochenqualität und eingeschränkter Compliance in der Nachbehandlung sind diese Versorgungen komplikationsträchtig. Das primäre Ziel der Versorgung älterer Patienten mit einer Sprunggelenkfraktur ist der Erhalt der Mobilität. Im Gegensatz zum jungen Patienten zeigen sich meist hochgradig instabile Pronation-Abduktion-Verletzungen. Bereits bei der Diagnostik sollten ein Erkennen und die Optimierung von Einflussfaktoren auf das Outcome wie z. B. der Durchblutung und der großzügige Einsatz der Computertomographie erfolgen. Wie beim jungen Patienten ist die konservative Therapie den stabilen Frakturformen vorbehalten und bei Vorliegen von Kontraindikationen gegen operative Maßnahmen auch bei instabilen Verletzungen einzuleiten. Anders ist die Wahl der Zugänge bei der operativen Therapie, die weichteiladaptiert, ggf. minimal-invasiv und zunehmend von posterolateral erfolgt. Die initiale Transfixation kann Weichteilproblematiken reduzieren. Spezielle operative Techniken und Implantate, die eine hohe Stabilität bieten, wie dorsale Plattenpositionierungen, Hakenplatten, winkelstabile Plattensysteme und intramedulläre Systeme, und zusätzliche Optionen wie Tibia-pro-Fibula-Konstrukte kommen zum Einsatz. Eine primäre retrograde Nagelarthrodese ist als „Salvage“-Verfahren nur Ausnahmefällen vorbehalten. Im Rahmen der Nachbehandlung erscheint ein interdisziplinärer Einsatz mit Respektierung und Optimierung von Begleiterkrankungen sinnvoll.

Abstract

As a result of the demographic developments ankle fractures in older patients are part of routine trauma surgery. Due to comorbidities, such as diabetes mellitus, reduced bone quality and limited compliance in follow-up treatment, these fractures are prone to complications. The primary goal in the treatment of older patients with ankle fractures is to maintain mobility. In contrast to young patients most fractures are unstable pronation-abduction injuries. In the diagnostics the recognition and optimization of factors influencing the outcome, such as the blood perfusion and the generous use of computed tomography (CT) are recommended. As in the case of younger patients, conservative treatment is reserved for stable fracture forms and, if there are contraindications, should also be initiated in the case of unstable injuries. The choice of approaches is different for surgical treatment, which is adapted to the soft tissues, if necessary minimally invasive and increasingly carried out by a posterolateral approach. The initial transfixation can reduce soft tissue problems. Special surgical techniques and implants that provide a high level of stability, such as dorsal plate positioning, hook plates, angular stable plate systems and intramedullary systems as well as additional options, such as tibia pro fibula constructs are used. Primary retrograde nail arthrodesis is reserved as a salvage procedure only for exceptional cases. As part of the follow-up treatment, an interdisciplinary approach with respect for and optimization of concomitant diseases seems to make sense.

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Change history

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Correspondence to Prof. Dr. Sabine Ochman.

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H. Polzer, München

S. Rammelt, Dresden

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Ochman, S., Raschke, M.J. Sprunggelenkfraktur beim älteren Patienten. Unfallchirurg 124, 200–211 (2021). https://doi.org/10.1007/s00113-021-00953-4

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Schlüsselwörter

  • Sprunggelenk
  • Fraktur
  • Alter
  • Osteosynthese
  • Komorbidität

Keywords

  • Ankle joint
  • Fracture
  • Elderly
  • Osteosynthesis
  • Comorbidity