T. Pohlemann

Epidemiology of pelvic ring injuries

3260 patients with pelvic and acetabular fractures were assessed using a standardized documentation form by collating the data on 1905 patients treated at the Department of Traumatology of the Hannover Medical School together with those patients treated between 1991 and 1993 in the German Multicentre Study Group (Pelvis) of the German Trauma Society and the German Section of the AO International. 2551 patients had pelvic ring injuries. 61.7% of the patients were multiply injured. 12.2% were suffering a complex pelvic trauma defined as a pelvic injury with concomitant soft tissue injury. The pelvic ring fracture was classified as stable in 54.8% (type A injury), as rotationally unstable in 24.7% (type B injury), and as unstable in translation in 20.5% (type C injury). There were concomitant acetabular fractures in 15.7%. The most frequent single lesions affecting the pelvic girdle were fractures of the ischiopubic bones (transpubic instability), injuries involving the sacroiliac joint (transiliosacral instability), and sacral fractures (transsacral instability). The overall rate of operative stabilizations was 21.6%. Type B injuries were stabilized in 28.9% and type C injuries in 46.7%. The overall mortality rate was 13.4%, depending significantly on the associated extrapelvic trauma. In complex pelvic injuries, the mortality rate was 31.1% whereas for pelvic fractures without concomitant soft tissue injury the rate was only 10.8%.

Outcome after pelvic ring injuries

Open reduction and internal fixation of unstable pelvic ring fractures provides the best stability of fixation as well as the best late clinical results. Whereas several studies have supported this both in biomechanical studies and clinical trials, there is still controversy about the long-term outcome of these injuries. A series of 58 patients who had received surgical stabilization of Tile B- and C-type fractures between 1985 and 1990 were followed up for an average of 28 months. The follow-up included a detailed clinical and radiological examination, an evaluation of the patients general social status and a detailed neurological and urological screening. The data were summarized in a new scoring system rating radiological, clinical and social results independently. Patients suffering B-type fractures showed 79% good and excellent results. Despite the fact that after C-type fractures 50% healed anatomically and 30% healed with a 5 mm or less residual posterior displacement, only 27% of the patients were rated good or excellent. Further studies must be conducted for closer evaluation of risk factors influencing the results after anatomical reconstruction of the pelvic ring.

Does the accident patient need to be protected from the emergency doctor

SummaryQuality control in preclinical medical care has become a matter of concern in recent years. In order to evaluate the quality of treatment one has to set standards. Most of the current standards were defined by different preclinical care organisations and are also accepted in the unique emergency medical care protocol used in the Federal Republic of Germany. Considering these standards, we retrospectively analyzed the preclinical treatment of all multiple trauma patients admitted to our department between 1985 and 1996. The major issues of this analysis were the diagnoses, the indications for invasive measures and the performance.Regarding the triage, for example, it was noted that 28 % of patients who should have been admitted to a level I trauma center considering the severity of their injury were first admitted to a level III hospital and needed to be transferred later. In 7 % of patients two additional mistakes and in 4 % of patients more than two mistakes in the triage were noted. On the other hand, there are records of patients who were considered to be only slightly injured but received invasive treatment.Preclinical intubation and mechanical ventilation was not performed in 16.5 % although the severity of injury clearly demanded it. A thoracic drain tube was not positioned in 38 % of patients suffering from severe thoracic trauma (AISThorax≥ 4). Insufficient application of resuscitation volume (< 2500 ml on admission) was evident in 17 % of all documented patients.According to our results, the initial evaluation of severity of injury is still a major problem and leads to wrong decisions for treatment. Although the qualification of ambulance physicians has been standardized for some years, there are still clear deficits in the preclinical management of trauma patients that need to be targeted.ZusammenfassungIn den letzten Jahren wurde zunehmend auch in der präklinischen Versorgung eine Qualitätsanalyse gefordert. Um die Qualität zu definieren und diese im Sinne der Qualitätssicherung kontrollieren, müssen Zielgrößen in Form von Standards festgeschrieben werden. Diese sind bereits unter Mitarbeit verschiedener deutscher Organisationen zusammengestellt worden, welches zu der Einführung eines bundeseinheitliches Notarztprotokolls geführt hat. Eine eigentliche Qualitätskontrolle dieser seit 1992 prospektiv dokumentierten Daten existiert jedoch nicht. Wir führten eine Auswertung aller polytraumatisierter Patientendaten durch, die mit einer definierten Verletzungsschwere primär oder sekundär in unsere Klinik eingeliefert wurden. Die Fehleranalyse beinhaltet wichtige Aspekte der präklinischen Diagnostik und Behandlung (Triage, Indikationsstellung und Ausführung von präklinischen Maßnahmen).Es zeigte sich, daß 28 % der Patienten, die aufgrund der Gesamtverletzungsschwere oder einer schwersten Einzelverletzung unmittelbar an ein Traumazentrum hätten transferriert werden müssen (Triage), primär in ein Krankenhaus der Regelversorgung eingeliefert wurden. Bei 7 % der Patienten ließ sich zwei und bei 4 % mehr als zwei Triagefehler nachweisen. Andererseits gab es Fälle, in denen trotz erkannter nur geringer Verletzungsschwere eine Intubation oder gar das Legen einer Thoraxdrainage erfolgte.Die präklinische Intubation und Beatmung wurde in 16,5 % der Fälle trotz klarer Indikation nicht durchgeführt. Eine Thoraxdrainage wurde trotz schwerem Thoraxtrauma (PTSThorax≥ 12/oder AISThorax≥ 4) und initialer Intubation und Beatmung bei 38 % nicht durchgeführt. Eine suffiziente Infusionstherapie (> 2500 ml effektiver Volumenersatz) war in 17 % der Fälle nicht erfolgt. Andererseits häufen sich Fälle in denen die Verletzungsschwere anscheinend überschätzt wurde und invasive Maßnahmen ergriffen wurden, die nach den vorhandenen Standards nicht indiziert gewesen wären.Diesen Ergebnissen zur Folge ist vorallem die Beurteilung der Verletzungsschwere am Unfallort häufig ein großes Problem, da hier der höchste Anteil vermeidbarer Fehler zu beobachten war. Ebenso wurde die Schwere des Thoraxtraumas vielfach falsch eingeschätzt und entsprechend nicht die erforderlichen Maßnahmen durchgeführt. Dies bedeutet, daß obwohl die Qualifikation des Notarztes nunmehr gesetzlich geregelt ist und Richtlinien für die Ausbildung erarbeitet sind, noch erhebliche Defizite in der Erkennung und Behandlung von Verletzungsfolgen bestehen. Einer Gefährdung des Unfallpatienten durch den Notarzt, der falsche Maßnahmen (im Sinne von zuviel oder zu wenig) ergreift, muß entgegengesteuert werden.

Different stabilisation techniques for typical acetabular fractures in the elderly—A biomechanical assessment

OBJECTIVES The tremendous increase of acetabular fractures in the elderly provides new challenges for their surgical treatment. The aim of this study was to evaluate the biomechanical properties of conventional and newly developed implants for the stabilisation of an anterior column combined with posterior hemitransverse fracture (ACPHTF), which represents the typical acetabular fracture in the elderly. METHODS Using a single-leg stance model we analysed four different implant systems for the stabilisation of ACPHTFs in synthetic and cadaveric pelvises. Applying an increasing axial load, fracture dislocation was analysed with a new multidirectional ultrasonic measuring system. Results of the different implant systems were compared by Scheffé post hoc test and one-way ANOVA. RESULTS In synthetic pelvises, the standard reconstruction plate fixed by 3 periarticular long screws and a new titanium fixator with multidirectional interlocking screws were associated with significantly less dislocation of the fractured quadrilateral plate of the acetabulum when compared to a standard reconstruction plate fixed by only one periarticular long screw and a locking reconstruction plate. No significant differences between the different osteosynthesis techniques could be observed in cadaver pelvises, probably due to a heterogeneous bone quality. CONCLUSIONS We conclude that the plate fixation by positioning of periarticular long screws as well as the multidirectional positioning of interlocking screws account for the most sufficient fracture stabilisation of ACPHTFs under experimental conditions.

Versorgungskonzept der Beckenringverletzung des alten Patienten

Whereas pelvic injuries in patients in their 20s and 30s are typically caused by high energy trauma, another group suffering this injury are elderly patients between the seventh and eighth decades of life. Due to osteoporosis and co-morbidities females are particularly affected by low energy trauma. After examining the medical history a physical examination of the pelvis is performed. This is followed by imaging with X-ray and CT scanning with 3D reconstruction if necessary. If there are concomitant injuries additional diagnostics are essential (e.g. sonography, MRI, retrograde ureterography, cystography and excretion urogram). The standard AO/ATO classification (Arbeitsgemeinschaft für Osteosynthesefragen/Orthopedic Trauma Association) has been well proven and does not depend on the age of the patient. Three different fracture types are differentiated, types A, B and C. This classification in combination with the description of the affected anatomical region (e.g. transsymphysis, transpubic, etc.) is sufficient in the daily clinical practice to decide on the necessary treatment. Often there are diagnostic difficulties in elderly patients (so-called differentiation of the A-B problem). In these patients a type A fracture is initially diagnosed and treated conservatively but due to persistent pain the imaging is repeated and an additional (insufficiency) fracture is found. With this new information the therapeutic regime has to be changed. The reconstruction of the pelvic ring is of major importance especially for elderly patients. This reduces the pain and the primary objective, an earliest possible rehabilitation without prolonged immobilization, can be achieved. In elderly patients external fixation with supra-acetabular screw positioning is an effective procedure and secondary insufficiency-instability (mostly dorsal) can be avoided. Whereas type A fractures can almost exclusively be treated non-surgically, types B and C fractures usually need surgery. As in young patients type B fractures are stabilized ventrally and C fractures dorsoventrally. In an emergency supra-acetabular external fixation and when required extraperitoneal tamponade has been established as the standard treatment for elderly patients in Germany. For the definitive surgical management standard procedures are used, but they often have to be modified depending on the bone structure.

Concept for treatment of pelvic ring injuries in elderly patients. A challenge

Whereas pelvic injuries in patients in their 20s and 30s are typically caused by high energy trauma, another group suffering this injury are elderly patients between the seventh and eighth decades of life. Due to osteoporosis and co-morbidities females are particularly affected by low energy trauma. After examining the medical history a physical examination of the pelvis is performed. This is followed by imaging with X-ray and CT scanning with 3D reconstruction if necessary. If there are concomitant injuries additional diagnostics are essential (e.g. sonography, MRI, retrograde ureterography, cystography and excretion urogram). The standard AO/ATO classification (Arbeitsgemeinschaft für Osteosynthesefragen/Orthopedic Trauma Association) has been well proven and does not depend on the age of the patient. Three different fracture types are differentiated, types A, B and C. This classification in combination with the description of the affected anatomical region (e.g. transsymphysis, transpubic, etc.) is sufficient in the daily clinical practice to decide on the necessary treatment. Often there are diagnostic difficulties in elderly patients (so-called differentiation of the A-B problem). In these patients a type A fracture is initially diagnosed and treated conservatively but due to persistent pain the imaging is repeated and an additional (insufficiency) fracture is found. With this new information the therapeutic regime has to be changed. The reconstruction of the pelvic ring is of major importance especially for elderly patients. This reduces the pain and the primary objective, an earliest possible rehabilitation without prolonged immobilization, can be achieved. In elderly patients external fixation with supra-acetabular screw positioning is an effective procedure and secondary insufficiency-instability (mostly dorsal) can be avoided. Whereas type A fractures can almost exclusively be treated non-surgically, types B and C fractures usually need surgery. As in young patients type B fractures are stabilized ventrally and C fractures dorsoventrally. In an emergency supra-acetabular external fixation and when required extraperitoneal tamponade has been established as the standard treatment for elderly patients in Germany. For the definitive surgical management standard procedures are used, but they often have to be modified depending on the bone structure.

Erectile dysfunction in relation to traumatic pelvic injuries or pelvic fractures

Because the interdisciplinary management of patients who sustain multiple trauma has improved, the survival of patients with pelvic fractures has increased in recent decades. This has resulted in a notable increase in the number of patients with lifelong disabilities from associated injuries to the urogenital organs, and with erectile dysfunction (ED). There is controversy as to whether ED develops as a result of the disruption caused by the primary pelvic trauma, or from the subsequent repair processes, or from iatrogenic lesions during the surgical repair of bony and soft tissue lesions. However, a comprehensive interdisciplinary evaluation of these patients shows autonomic neurogenic lesions to be the predominant cause for post-traumatic ED. This aetiology is of practical importance for the treatment options offered to the patient.

Classification of acetabular fractures. A systematic analysis of the relevance of computed tomography

SummaryThe classification of acetabular fractures and especially the diagnosis of additional lesions can be misleading, when the personal experience is limited and the decisions are based only on conventional radiographs. The introduction of Spiral-CT with multiplanar reformations and 3-D views has improved the quality of visualization. Due to their higher costs, the need of these additional diagnostic tools is frequently questioned. This paper discusses the relevance of plain radiographs, 2-D-CTs, 3-D-CTs and Femursubtraction-CTs (FsCT) for the classification of acetabular fractures, based on a controlled study. Methods: Thirty physicians with different levels of experience in acetabular surgery were divided in three groups of 10 each: group I comprised residents without operative experience in acetabular surgery, group II was physicians with 3–10 years of operative experience, and group III was experts in acetabular surgery. A total of 10 complete radiographic cases of high quality providing all levels of preoperative diagnostics (plain radiographs, 2-D-CT, CT with multiplanar reformation, 3-D-CT, Fs-CT) of different acetabular fracture types were prepared. The task for each candidate was to classify the fracture according to Letournel and to identify all additional injuries within the hip joint (e. g. marginal impaction, head fractures, etc.). The different diagnostic “levels” could be ordered stepwise according to personal need and no time limit was given. The case was finished when the candidate presented his final diagnosis. The use of the different radiographs, the preliminary diagnosis, the changes in diagnosis, and the final decisions were recorded. These findings were correlated with the different levels of experience and against a “consensus classification” which was generated by thorough discussion, and the use of intraoperative information and postoperative radiographs not accessible to the candidates. Results: The “correct” fracture classification based on plain radiographs was: group I, 11 %; group II, 32 %; group III, 61 %. Based on 2-D-CT a “correct” diagnosis was reached by 30 % in group I, by 55 % in group II, and by 76 % in group III. With consideration of the “transient forms” in acetabular fractures based on Letournel and the 3-D-CT used mainly by group I, the rate of “correct” classifications rose to 65 % in group I, 64 % in group II and 83 % in group III. The modifiers were diagnosed “correctly” in group I by 37 %, in group II by 56 %, and in group III by 73 %. The use of the 3-D-CT and especially the Fs-CT by group I resulted in an improvement in the rate of correct classifications to 61 %, whereas in group II the Fs-Ct was used only exceptionally. The 2-D-CT was the basis for the diagnosis of the additional lesions in acetabular fractures within all groups resulting in 73 % complete diagnoses in group III. This study showed the importance of CT for the exact analysis and classification of acetabular fractures. In particular, the secondary reformations in CT and the 3-D-views dramatically improved the rate of “correct” classifications in the group of surgeons with limited personal experience in acetabular surgery. This allows the less experienced an acceptable level of “correct” diagnoses, so that the treatment options can be weighed correctly. Among the “experts” a rate of divergent classifcations of approximately 20 % was observed, especially in “transient” forms of acetabular fractures.ZusammenfassungDie Klassifikation von Acetabulumfrakturen und besonders die Diagnose von Zusatzläsionen ist anhand der konventionellen Aufnahmen oftmals schwierig. Schon früh wurde auf die Wertigkeit der axialen Computertomographie (CT) hingewiesen. In den letzten Jahren haben sich durch Einführung der Spiral-CT mit optimierten multiplanaren- und dreidimensionalen (3D-)Rekonstruktionen die Darstellungsmöglichkeiten erheblich erweitert. In der vorliegenden Studie wird die Wertigkeit der einzelnen diagnostischen Stufen auf die Qualität der Klassifikation der Fraktur, das Erkennen von acetabulären Zusatzverletzungen und die Entscheidungsfindung zwischen Unfallchirurgen mit unterschiedlicher persönlicher Erfahrung untersucht. Von 10 Patienten mit gut dokumentierten Acetabulumfrakturen wurden vollständige radiologische Verläufe zusammengestellt (Nativaufnahmen mit Schrägaufnahmen, axiale CT, Reformationen, 3D-CT und Femursubtraktions-CT). Die vorgegebene „Referenzklassifikation“ wurde unter Einbeziehung der den Probanden nicht zugänglichen intraoperativen Informationen festgelegt. Diese Verläufe wurden 30 Unfallchirurgen, bzw. Assistenten in unfallchirurgischer Weiterbildung zur Klassifikation der Acetabulumfraktur und Diagnose von Zusatzverletzungen (intraartikuläre Fragmente, Acetabulumimpressionen) vorgelegt. Es wurden 3 Gruppen gebildet: Gruppe I: Fachärzte ohne, Gruppe II: 3- bis 10 jährige und Gruppe III mit über 10 jähriger Erfahrung in der Beckenchirurgie. Zur Auswertung kamen somit 300 Einzelentscheidungen. Die „richtige“ Klassifikation, d. h. mit der vorgegebenen übereinstimmend, wurde ausschließlich mit konventionellen Aufnahmen in Gruppe I in 11 %, in Gruppe II zu 32 %, in Gruppe III zu 61 % gestellt. Nach der 2-D-CT-Diagnostik wurden „richtige“ Klassifikationen zu 30 % in Gruppe I, zu 55 % in Gruppe II und zu 76 % in Gruppe III gestellt. Unter Berücksichtigung der Übergangsformen und der 3-D-Darstellungen vorwiegend durch Gruppe I wurde eine Übereinstimmung in der Klassifikation in Gruppe I in 65 %, Gruppe II in 64 % und in Gruppe III in 83 % festgestellt. Untersucherabhängig kam es bei den „Unerfahrenen“ häufiger zu einer Korrektur der ursprünglich angenommenen Klassifikation. Zusatzpathologien wurden in Gruppe I zu 37 %, in Gruppe II zu 56 % und in Gruppe III zu 73 % erkannt, überwiegend nach dem 2D-CT. In der vorliegenden Arbeit konnte die hohe Bedeutung der CT zur exakten Klassifikation der Acetabulumfrakturen bestätigt werden. Insbesondere die zwischenzeitlich weit verbreiteten Möglichkeiten der sekundären Datenbearbeitung (multiplanare Reformationen, 3D-CT etc.) erlaubt auch dem „Unerfahrenen“ eine ausreichend hohe Diagnosesicherheit, um für den Patienten ggf. schwerwiegende Fehlentscheidungen (Indikationsstellung, Zugangswahl) zu vermeiden. Aber auch unter „Experten“ muß in ca. 20 % der Fälle mit nicht übereinstimmenden Klassifizierungen gerechnet werden, vorwiegend bei den Übergangsformen und kombinierten Acetabulumfrakturen.

Injuries of the pelvic ring in road traffic accidents: a medical and technical analysis.

Between 1985 and 1995, 9380 traffic accidents occurring in the area of Hannover, Germany, were analysed; 12428 individuals had been injured and 387 (3.1%) had sustained a pelvic-ring injury (AIS(PELVIS)>2). In 131 cases (34%), the injuries were further classified (Pennal and Tile) and a technical reconstruction made of the accident: 52% were type A, 27% type B and 21% type C injuries; 46% were in cars, 12% on motorised two-wheelers, 10% on bicycles and 1% in utility vehicles; 31% were pedestrians. Pelvic-ring injuries occurred in restrained vehicle occupants in accidents with a (delta)V of more than 30 km/h, whereas they occurred in a considerable proportion of unrestrained vehicle occupants, pedestrians and bicyclists at lower (delta)V or collision speed. The percentage of B- and C-type injuries increased in crashes with higher (delta)v or collision speed. In addition to further improvements of the passive safety, lower collision speeds or (delta)V would reduce or prevent pelvic-ring injuries. Due to the small number of occupants protected by airbags in this study, their protective effect for the pelvis could not be assessed. The reconstruction of pelvic-ring injury mechanism in traffic accidents is possible when technical and medical factors are considered.

[Application of the pelvic C-clamp].

ZusammenfassungDie instabile Beckenringverletzung in Kombination mit der schweren beckenbedingten Blutung geht mit hoher Letalität einher. Durch den Einsatz der Notfall-Beckenzwinge nach Ganz kann die Prognose verbessert werden. Sie kann schon während der lebensrettenden Maßnahmen durchgeführt werden und sollte gegebenenfalls mit einer pelvinen Tamponade kombiniert werden. Wegen der geringen Patientenzahlen verfügen vor allem die Traumazentren der Maximalversorgung über Erfahrung mit der Methode. In dem vorliegenden Beitrag wird eine im eigenen Vorgehen entwickelte, standardisierte Anlagetechnik dargestellt. Sie ermöglicht die sichere Anwendung des Verfahrens durch die Verwendung von gut definierten klinisch erkennbaren Orientierungspunkten im Schockraum.AbstractUnstable pelvic girdle injury combined with severe pelvis related haemorrhage has a high mortality rate. This prognosis can be improved by using the C-clamp according to Ganz. This can be applied while the life saving measures are in progress, and should, if necessary, be combined with a pelvic tamponade. Due to the limited number of patients, trauma centres have the most experience with this technique. In this contribution, we present our standardised application technique, which allows the use of the procedure through well defined clinically recognisable orientation points in the emergency room.