minor trauma-pearls and pitfalls für den Grundversorger

minor trauma-pearls and pitfalls für den Grundversorger

(Edition OSG)Senad Tabakovic, 01.07.2021

Ostschweizer Notfallsymposium

ein Hausarzt und ein Notfallmediziner gehen in eine Bar…

• keine Patientenvorselektion

• Arbeit unter Zeitdruck

• Spannungsfeld zw. schonendem Ressourceneinsatz und qualitativ guter Medizin

• Generalisten

Heuristiken

Workshop-Pub Quiz

Muharem

• 56 jährig

• Treppensturz, von der dritt obersten Stufe gesprungen und bei der Landung den Knöchel „irgendwie“ verstaucht

• hinkt, kann belasten unter Schmerzen

• Diabetiker und Hypertoniker

Braucht er ein Röntgenbild?

Ottawa ankle rules

Unfähigkeit zu Belasten ist der beste Frakturprädiktor

Vorsicht bei:

• Intoxikation

• unkooperativen Patienten

• ablenkenden Schmerzen

• verminderter Sensibilität in den Beinen

• starke Schwellung, die eine exakte Palpation verhindert

Was ist Muharems Diagnose?

Fraktur Proc lateralis tali

Was ist die klassische Sportart, bei der diese Fraktur auftritt?

Snowboarder Fraktur

Aussenrotation + Dorsalflexion + axiale Stauchung

Wie viele dieser Frakturen (in Prozent) werden gemäss Literatur im

konventionellen Röntgen verpasst?

40-50%

„Talus ist das Scaphoid des OSGs“

Literatur

1. Pijnenburg AC, Glas AS, De Roos MA, et al. Radiography in acute ankle injuries: the Ottawa ankle rules versus local diagnostic decision rules. Ann Emerg Med. 2002;39(6):599–604. 2. Markert RJ, Walley ME, Guttman TG, Mehta R. A pooled analysis of the Ottawa ankle rules used on adults in the ED. Am J Emerg Med. 1998;16(6):564–567. 3. Pigman EC, Klug RK, Sanford S, Jolly BT. Evaluation of the Ottawa clinical decision rules for the use of radiography in acute ankle and midfoot injuries in the emergency department:

an independent site assessment. Ann Emerg Med. 1994;24(1):41–45. 4. Lucchesi GM, Jackson RE, Peacock WF, Cerasani C, Swor RA. Sensitivity of the Ottawa rules. Ann Emerg Med. 1995;26(1):1–5. 5. McBride KL. Validation of the Ottawa ankle rules. Experience at a community hospital. Can Fam Physician. 1997;43:459–465.6. Auleley GR, Ravaud P, Giraudeau B, et al. Implementation of the Ottawa ankle rules in France. A multicenter randomized controlled trial. JAMA. 1997;277(24):1935–1939. 7. Salt P, Clancy M. Implementation of the Ottawa ankle rules by nurses working in an accident and emergency department. J Accid Emerg Med. 1997;14(6):363–365. 8. Auleley GR, Kerboull L, Durieux P, Cosquer M, Courpied JP, Ravaud P. Validation of the Ottawa ankle rules in France: a study in the surgical emergency department of a teaching

hospital. Ann Emerg Med. 1998;32(1):14–18. 9. Mann CJ, Grant I, Guly H, Hughes P. Use of the Ottawa ankle rules by nurse practitioners. J Accid Emerg Med. 1998;15(5):315–316.10.Perry S, Raby N, Grant PT. Prospective survey to verify the Ottawa ankle rules. J Accid Emerg Med. 1999;16(4):258–260. 11.Tay SY, Thoo FL, Sitoh YY, Seow E, Wong HP. The Ottawa ankle rules in Asia: validating a clinical decision rule for requesting x-rays in twisting ankle and foot injuries. J Emerg Med.

1999;17(6):945–947. 12.Springer BA, Arciero RA, Tenuta JJ, Taylor DC. A prospective study of modified Ottawa ankle rules in a military population. Am J Sports Med. 2000;28(6):864–868.13.Yuen MC, Sim SW, Lam HS, Tung WK. Validation of the Ottawa ankle rules in a Hong Kong ED. Am J Emerg Med. 2001;19(5):429–432. 14.Broomhead A, Stuart P. Validation of the Ottawa ankle rules in Australia. Emerg Med (Fremantle). 2003;15(2):126–132. 15.Fiesseler F, Szucs P, Kec R, Richman PB. Can nurses appropriately interpret the Ottawa ankle rule? Am J Emerg Med. 2004;22(3):145–148. 16.Bachmann LM, Kolb E, Koller MT, Steurer J, ter Riet G. Accuracy of Ottawa ankle rules to exclude fractures of the ankle and mid-foot: systematic review. BMJ. 2003;326(7386):417. 17.Dowling S, Spooner CH, Liang Y, et al. Accuracy of Ottawa Ankle Rules to exclude fractures of the ankle and midfoot in children: a meta-analysis. Acad Emerg Med. 2009;16(4):277–

287. doi:10.1111/j.1553–2712.2008.00333.x. Epub 2009 Feb 2. 18.Coll AP. Ottawa rules, OK? Rules are different in diabetes. BMJ. 2009;339:b3507. doi:10.1136/bmj.b3507.

Olivia

• 16 jährig

• Kunstturnerin

• Schmerzen OSG links seit 2-3 Wochen

• keine Mens seit 3 Monaten

Braucht sie ein Röntgenbild?

Was ist die Diagnose?

Stressfraktur der distalen

Tibia

Wie häufig werden Stressfrakturen im Röntgenbild verpasst?

in 9 von 10 Fällen!

In welchem Knochen treten beim Menschen die meisten Stressfrakturen

auf?

Tibia

Welche Art der Bildgebung zeigt die Stressfraktur am zuverlässigsten?

MRI

Was könnte die Ursache der Fraktur

sein?

female athlete triad

Wichtige Punkte!

Stress- und Insuffizienzfrakturen: in einem von zehn Fällen im Rx sichtbar

Fraktur als Symptom

Ernährungs- und Bewegungsanamnese

Angststörung und Depression suchen

Literatur1. Weiss Kelly AK, Hecht S; COUNCIL ON SPORTS MEDICINE AND FITNESS. The Female Athlete Triad. Pediatrics. 2016;138(2):e20160922. PMID: 27432852.

2. Nichols JF, Rauh MJ, Lawson MJ, Ji M, Barkai HS. Prevalence of the female athlete triad syndrome among high school athletes. Arch Pediatr Adolesc Med. 2006;160(2):137-142. doi:10.1001/archpedi.160.2.137. PMID: 16461868.

3. Hoch AZ, Pajewski NM, Moraski L, et al. Prevalence of the female athlete triad in high school athletes and sedentary students. Clin J Sport Med. 2009;19(5):421-428. doi:10.1097/JSM.0b013e3181b8c136. PMID: 19741317.

4. Matcuk GR Jr, Mahanty SR, Skalski MR, Patel DB, White EA, Gottsegen CJ. Stress fractures: pathophysiology, clinical presentation, imaging features, and treatment options. Emerg Radiol. 2016;23(4):365-375. PMID: 27002328.

5. Saunier J, Chapurlat R. Stress fracture in athletes. Joint Bone Spine. 2018;85(3):307-310. PMID: 28512006.

6. Matheson GO, Clement DB, McKenzie DC, Taunton JE, Lloyd-Smith DR, MacIntyre JG. Stress fractures in athletes. A study of 320 cases. Am J Sports Med. 1987;15(1):46-58. doi:10.1177/036354658701500107. PMID: 3812860.

7. Denay KL. Stress Fractures. Curr Sports Med Rep. 2017;16(1):7-8. PMID: 28067732.

8. McInnis KC, Ramey LN. High-Risk Stress Fractures: Diagnosis and Management. PM R. 2016;8(3 Suppl):S113-S124. PMID: 26972260.

9. Otis CL, Drinkwater B, Johnson M, Loucks A, Wilmore J. American College of Sports Medicine position stand. The Female Athlete Triad. Med Sci Sports Exerc. 1997;29(5):i-ix. PMID: 9140913.

10. Nattiv A, Loucks AB, Manore MM, et al. American College of Sports Medicine position stand. The female athlete triad. Med Sci Sports Exerc. 2007;39(10):1867-1882. PMID: 17909417.

11. Sundgot-Borgen J. Risk and trigger factors for the development of eating disorders in female elite athletes. Med Sci Sports Exerc. 1994;26(4):414-419.PMID: 8201895.

12. Scofield KL, Hecht S. Bone health in endurance athletes: runners, cyclists, and swimmers. Curr Sports Med Rep. 2012;11(6):328-334. PMID: 23147022.

https://pubmed-ncbi-nlm-nih-gov.neomed.idm.oclc.org/27432852/


https://www-ncbi-nlm-nih-gov.neomed.idm.oclc.org/pmc/articles/PMC2848387/










Valerie

• 26 jährig

• vom Pferd gestürzt und sich den Fuss verknackst

• konnte schmerzbedingt nicht mehr belasten


isolierte Fraktur posteriorer Malleolus

CT nach 3 Tagen

Welche Begleitverletzung suchen Sie radiologisch?

Maisonneuve Fraktur

Mythbuster: Fehlen von Schmerzen entlang der Fibula schliesst die Fraktur nicht aus

Aussenrotation +/- axiale Stauchung

Wichtige Punkte!

isolierte posteriore Malleolarfrakturen selten (1% aller OSG Fx) und oft übersehen

häufig mit anderen Verletzungen im OSG zusammen

Unfallmechanismus genau nachzuvollziehen versuchen!

Literatur1. Court-Brown C.M., Caesar B. Epidemiology of adult fractures: a review. Injury. 2006;37(August (8)):691–697. [PubMed] [Google Scholar]

2. Odak S., Ahluwalia R., Unnikrishnan P., Hennessy M., Platt S. Management of posterior malleolar fractures: a systematic review. J. Foot Ankle Surg. 2016;55(January (1)):140–145. [PubMed] [Google Scholar]

3. Hou Z., Zhang L., Zhang Q., Yao S., Pan J., Irgit K. The communication line suggests occult posterior malleolar fracture associated with a spiral tibial shaft fracture. Eur. J. Radiol. 2012;81(March (3)):594–597. [PubMed] [Google Scholar]

4. Fu S., Zou Z.Y., Mei G., Jin D. Advances and disputes of posterior malleolus fracture. Chin. Med. J. (Engl.) 2013;126(October (20)):3972–3977. [PubMed] [Google Scholar]

5. Donken C.C., Goorden A.J., Verhofstad M.H., Edwards M.J., van Laarhoven C.J. The outcome at 20 years of conservatively treated ‘isolated’ posterior malleolar fractures of the ankle: a case series. J. Bone Joint Surg. Br. 2011;93(December (12)):1621–1625. [PubMed] [Google Scholar]

6. Neumaier P.E., Maas R., Meenen N.M. Isolated fracture of the posterolateral tibial lip (Volkmann's triangle) Acta Radiol. 1997;38(May (3)):359–362. [PubMed] [Google Scholar]

7. Bartonicek J. Avulsed posterior edge of the tibia. Earle's or Volkmann's triangle? J. Bone Joint Surg. Br. 2004;86(July (5)):746–750. [PubMed] [Google Scholar]

8. Earle H. Simple, succeeded by compound dislocation forwards, of the inferior extremity of the tibia, with fracture of its posterior edge, comminuted fracture of the fibula, amputation of the leg, and death. Lancet. 2017;1828-29(II/6):346–348. [Google Scholar]

9. Ozler T., Guven M., Onal A., Ulucay C., Beyzadeoglu T., Altintas F. Missed isolated posterior malleolar fractures. Acta Orthop. Traumatol. Turc. 2014;48(3):249–252. [PubMed] [Google Scholar]

10. Agha R.A., Fowler A.J., Saeta A., Barai I., Rajmohan S., Orgill D.P. The SCARE statement: consensus-based surgical case report guidelines. Int. J. Surg. 2016;34(October):180–186. [PubMed] [Google Scholar]

11. Stiell I.G., Greenberg G.H., McKnight R.D., Nair R.C., McDowell I., Reardon M. Decision rules for the use of radiography in acute ankle injuries: refinement and prospective validation. JAMA. 1993;269(March (9)):1127–1132. [PubMed] [Google Scholar]

12. Olerud C., Molander H. A scoring scale for symptom evaluation after ankle fracture. Arch. Orthop. Trauma Surg. 1984;103(3):190–194. [PubMed] [Google Scholar]

13. Boggs L.R. Isolated posterior malleolar fractures. Am. J. Emerg. Med. 1986;4(July (4)):334–336. [PubMed] [Google Scholar]

14. Bourdon A., Granier P., Mourad M. Diagnosis of an isolated occult fracture of the posterior margin of the tibia with the SPECT/CT. Med Nucl. 2008;32(12):614–619. [Google Scholar]

15. Buschmeyer R., Moschinski D. Isolated fracture of the posterior distal tibial margin, the so-called posterior Volkmann triangle. Unfallheilkunde. 1984;87(November (11)):474–478. [PubMed] [Google Scholar]

https://www.ncbi.nlm.nih.gov/pubmed/16814787

https://scholar.google.com/scholar_lookup?journal=Injury&title=Epidemiology+of+adult+fractures:+a+review&author=C.M.+Court-Brown&author=B.+Caesar&volume=37&issue=August+(8)&publication_year=2006&pages=691-697&pmid=16814787&


https://scholar.google.com/scholar_lookup?journal=J.+Foot+Ankle+Surg.&title=Management+of+posterior+malleolar+fractures:+a+systematic+review&author=S.+Odak&author=R.+Ahluwalia&author=P.+Unnikrishnan&author=M.+Hennessy&author=S.+Platt&volume=55&issue=January+(1)&publication_year=2016&pages=140-145&pmid=26100091&


https://scholar.google.com/scholar_lookup?journal=Eur.+J.+Radiol.&title=The+communication+line+suggests+occult+posterior+malleolar+fracture+associated+with+a+spiral+tibial+shaft+fracture&author=Z.+Hou&author=L.+Zhang&author=Q.+Zhang&author=S.+Yao&author=J.+Pan&volume=81&issue=March+(3)&publication_year=2012&pages=594-597&pmid=21316885&

tel:3972%E2%80%933977


https://scholar.google.com/scholar_lookup?journal=Chin.+Med.+J.+(Engl.)&title=Advances+and+disputes+of+posterior+malleolus+fracture&author=S.+Fu&author=Z.Y.+Zou&author=G.+Mei&author=D.+Jin&volume=126&issue=October+(20)&publication_year=2013&pages=3972-3977&pmid=24157167&


https://scholar.google.com/scholar_lookup?journal=J.+Bone+Joint+Surg.+Br.&title=The+outcome+at+20+years+of+conservatively+treated+%E2%80%98isolated%E2%80%99+posterior+malleolar+fractures+of+the+ankle:+a+case+series&author=C.C.+Donken&author=A.J.+Goorden&author=M.H.+Verhofstad&author=M.J.+Edwards&author=C.J.+van+Laarhoven&volume=93&issue=December+(12)&publication_year=2011&pages=1621-1625&pmid=22161924&


https://scholar.google.com/scholar_lookup?journal=Acta+Radiol.&title=Isolated+fracture+of+the+posterolateral+tibial+lip+(Volkmann%27s+triangle)&author=P.E.+Neumaier&author=R.+Maas&author=N.M.+Meenen&volume=38&issue=May+(3)&publication_year=1997&pages=359-362&pmid=9191423&


https://scholar.google.com/scholar_lookup?journal=J.+Bone+Joint+Surg.+Br.&title=Avulsed+posterior+edge+of+the+tibia.+Earle%27s+or+Volkmann%27s+triangle?&author=J.+Bartonicek&volume=86&issue=July+(5)&publication_year=2004&pages=746-750&pmid=15274275&

https://scholar.google.com/scholar_lookup?journal=Lancet&title=Simple,+succeeded+by+compound+dislocation+forwards,+of+the+inferior+extremity+of+the+tibia,+with+fracture+of+its+posterior+edge,+comminuted+fracture+of+the+fibula,+amputation+of+the+leg,+and+death&author=H.+Earle&volume=1828-29&issue=II/6&publication_year=2017&pages=346-348&


https://scholar.google.com/scholar_lookup?journal=Acta+Orthop.+Traumatol.+Turc.&title=Missed+isolated+posterior+malleolar+fractures&author=T.+Ozler&author=M.+Guven&author=A.+Onal&author=C.+Ulucay&author=T.+Beyzadeoglu&volume=48&issue=3&publication_year=2014&pages=249-252&pmid=24901912&


https://scholar.google.com/scholar_lookup?journal=Int.+J.+Surg.&title=The+SCARE+statement:+consensus-based+surgical+case+report+guidelines&author=R.A.+Agha&author=A.J.+Fowler&author=A.+Saeta&author=I.+Barai&author=S.+Rajmohan&volume=34&issue=October&publication_year=2016&pages=180-186&pmid=27613565&


https://scholar.google.com/scholar_lookup?journal=JAMA&title=Decision+rules+for+the+use+of+radiography+in+acute+ankle+injuries:+refinement+and+prospective+validation&author=I.G.+Stiell&author=G.H.+Greenberg&author=R.D.+McKnight&author=R.C.+Nair&author=I.+McDowell&volume=269&issue=March+(9)&publication_year=1993&pages=1127-1132&pmid=8433468&


https://scholar.google.com/scholar_lookup?journal=Arch.+Orthop.+Trauma+Surg.&title=A+scoring+scale+for+symptom+evaluation+after+ankle+fracture&author=C.+Olerud&author=H.+Molander&volume=103&issue=3&publication_year=1984&pages=190-194&pmid=6437370&


https://scholar.google.com/scholar_lookup?journal=Am.+J.+Emerg.+Med.&title=Isolated+posterior+malleolar+fractures&author=L.R.+Boggs&volume=4&issue=July+(4)&publication_year=1986&pages=334-336&pmid=3718625&

https://scholar.google.com/scholar_lookup?journal=Med+Nucl&title=Diagnosis+of+an+isolated+occult+fracture+of+the+posterior+margin+of+the+tibia+with+the+SPECT/CT&author=A.+Bourdon&author=P.+Granier&author=M.+Mourad&volume=32&issue=12&publication_year=2008&pages=614-619&


https://scholar.google.com/scholar_lookup?journal=Unfallheilkunde&title=Isolated+fracture+of+the+posterior+distal+tibial+margin,+the+so-called+posterior+Volkmann+triangle&author=R.+Buschmeyer&author=D.+Moschinski&volume=87&issue=November+(11)&publication_year=1984&pages=474-478&pmid=6516037&

Jürgen

• Am Vortag: Treppen hinunter gerannt, Stufe verpasst, mit der Ferse an der Stufe hängen geblieben, Misstritt

• kann nicht mehr belasten

• gesund


Lisfranc Verletzung

Alignement

Alignement

Gap zw. Os cuneiforme mediale und Basis Metatarsale II > 2mm

Mechanismus bei Trauma mit niedriger Energie

Was sieht man hier? Wie heisst das Zeichen?

Fleck sign

Klinik

Wichtige Punkte!

• Mechanismus, Klinik und radiologische Zeichen

• Bei klinischem Verdacht und normalem Röntgen erweiterte Diagnostik anstreben

• Wenn Patient belasten kann, Aufnahme unter Belastung, ev. im Seitenvergleich oder direkt CT.

Dr. Lisfranc

Lisfranc

„ein grosser Blutabzapfer und Abhacker von Körperteilen“

„Im Blutrausch, wie er anordnete, seine Patienten samt und sonders zur Ader zu lassen, was auch immer ihnen fehlte“

Wie lange hat Dr. Lisfranc für die

tarsometatarsale Amputation gebraucht?

Weniger als 1 Minute

Literatur1. Siddiqui NA, Galizia MS, Almusa E, et al. Evaluation of the tarsometatarsal joint using conventional radiography, CT,

and MR imaging. Radiographics. 2014;34(2):514-531.

2. Lau S, Bozin M, Thillainadesan T. Lisfranc fracture dislocation: a review of a commonly missed injury of the midfoot. Emerg Med J. 2017;34(1):52-56.

3. Caswell F, Brown C. Identifying foot fractures and dislocations. Emerg Nurse. 2014;22(6):30-34.

4. Englanoff G, Anglin D, Hutson HR. Lisfranc fracture-dislocation: a frequently missed diagnosis in the emergency department. Ann Emerg Med. 1995;26(2):229-233.

5. Anderson RB, Hunt KJ, McCormick JJ. Management of common sports-related injuries about the foot and ankle. J Am Acad Orthop Surg. 2010;18(9):546-556.

6. Buzzard BM, Briggs PJ. Surgical management of acute tarsometatarsal fracture dislocation in the adult. Clin Orthop Relat Res. 1998;(353):125-133.

7. Harwood MI, Raikin SM. A Lisfranc fracture-dislocation in a football player. J Am Board Fam Pract. 2003;16(1):69-72.

https://www.ncbi.nlm.nih.gov/pubmed?term=Evaluation+of+the+tarsometatarsal+joint+using+conventional+radiography%2C+CT%2C+and+MR+imaging&TransSchema=title&cmd=detailssearch

https://www.ncbi.nlm.nih.gov/pubmed?term=Lisfranc+fracture+dislocation%3A+a+review+of+a+commonly+missed+injury+of+the+midfoot&TransSchema=title&cmd=detailssearch

https://www.ncbi.nlm.nih.gov/pubmed?term=Identifying+foot+fractures+and+dislocations&TransSchema=title&cmd=detailssearch

https://www.ncbi.nlm.nih.gov/pubmed?term=Lisfranc+fracture-dislocation%3A+a+frequently+missed+diagnosis+in+the+emergency+department&TransSchema=title&cmd=detailssearch

https://www.ncbi.nlm.nih.gov/pubmed?term=Management+of+common+sports-related+injuries+about+the+foot+and+ankle&TransSchema=title&cmd=detailssearch

https://www.ncbi.nlm.nih.gov/pubmed?term=Surgical+management+of+acute+tarsometatarsal+fracture+dislocation+in+the+adult&TransSchema=title&cmd=detailssearch

https://www.ncbi.nlm.nih.gov/pubmed?term=A+Lisfranc+fracture-dislocation+in+a+football+player&TransSchema=title&cmd=detailssearch

Take home

• Mechanismus so genau wie möglich erfragen

• Aussenrotationsmechanismus und Unfähigkeit zu belasten als Red Flags beim OSG

• Vorerkrankungen berücksichtigen

• immer auch den ganzen Fuss und Unterschenkel untersuchen

• Ottawa ankle rules

Vielen Dank für die Aufmerksamkeit

Documents

minor trauma-pearls and pitfalls für den Grundversorger