Operative Versorgungsstrategien beim Polytrauma mit Beckenfraktur

Objective

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.

Methods

Clinical trials were systematically collected (MEDLINE, Cochrane, and hand searches), reviewed, and classified into evidence levels (1 to 5 according to the Oxford system).

Results

According to the literature there is consensus on “early” operative stabilization of multiply injured patients with hemodynamically and mechanically unstable pelvic fractures, open pelvic fractures, or complex pelvic trauma. External fixation and the pelvic C-clamp are the methods of choice in emergency situations, whereas currently internal fracture fixation is only proposed in exceptional circumstances. In contrast, the point in time for the secondary definitive fracture stabilization remains controversially discussed. This discussion ranges from the postulation that extensive definitive fracture treatment be avoided during days 2–4 after trauma to the recommendation that definitive internal fixation of pelvic fractures be undertaken early, i.e., within the 1st week after trauma.

Conclusion

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.     

Significance of Computed Tomography Finding of Intra-Abdominal Free Fluid Without Solid Organ Injury after Blunt Abdominal Trauma: Time for Laparotomy on Demand

Background

Optimal management of patients with intra-abdominal free fluid found on computed tomography (CT) scan without solid organ injury remains controversial.

Objective

The purpose of this study was to determine the significance of CT scan findings of free fluid in the management of blunt abdominal trauma patients who otherwise have no indications for laparotomy.

Methods

During the 3-year study period, all patients presenting with blunt abdominal trauma who underwent abdominal CT examination were retrospectively reviewed. All hemodynamically stable patients who presented with abdominal free fluid without solid organ injury on CT scan were analyzed for radiological interpretation, clinical management, operative findings, and outcome.

Results

A total of 122 patients were included in the study, 91 % of whom were males. The mean age of the patients was 33 ± 12 years. A total of 34 patients underwent exploratory laparotomy, 31 of whom had therapeutic interventions. Small bowel injuries were found in 12 patients, large bowel injuries in ten, and mesenteric injuries in seven patients. One patient had combined small and large bowel injury, and one had traumatic gangrenous appendix. In the remaining three patients, laparotomy was non-therapeutic. A total of 36 patients had associated pelvic fractures and 33 had multiple lumbar transverse process fractures.

Conclusion

Detection of intra-peritoneal fluid by CT scan is inaccurate for prediction of bowel injury or need for surgery. However, the correlation between CT scan findings and clinical course is important for optimal diagnosis of bowel and mesenteric injuries.     

Is preoperative period associated with severity and unexpected death of injured patients needing emergency trauma surgery?

Purpose

Early operative control of hemorrhage is the key to saving the lives of severe trauma patients. We investigated whether emergency room (ER) stay time [time from the ER to the operating room (OR)] is associated with trauma severity and unexpected trauma death [Trauma and Injury Severity Score (TRISS) method-based probability of survival (Ps) ≥0.5 but died] of injured patients needing emergency trauma surgery.

Methods

We performed a retrospective review of all trauma patients requiring emergency surgery and all patients with pelvic fractures requiring transcatheter arterial embolization at our hospital from January 2002 to December 2012. We analyzed the relationships among injury severity on ER admission [Injury Severity Score (ISS); Revised Trauma Score (RTS); Ps; Shock Index (SI); American Society of Anesthesiologists Physical Status (ASA-PS)]; mortality rate; unexpected trauma death rate; and ER stay time.

Results

ER stay times were significantly shorter for patients with life-threatening conditions [RTS <6.0 (p < 0.01), Ps <0.5 (p < 0.001), SI ≥1.0 (p < 0.01), and ASA-PS ≥4E (p < 0.001)]. In particular, ER stay time was inversely related to injury severity up to 120 min. The risk of unexpected trauma death significantly increased as ER stay time increased over 90 min (p < 0.01).

Conclusions

Our results suggest that all medical staff should work together effectively on high-risk patients in the ER, bringing them immediately to the OR according to their level of risk. If injured patients need emergency trauma surgery, ER stay times should be kept as short as possible to reduce unexpected trauma death.     

Schnittstellen in der Notfallmedizin

Introduction

The known health care chain for the most severely injured patients can represent an additional risk potential in the field of interfaces within different health care stages.

Problem

Apart from inadequate equipment, different treatment algorithms and hierarchies, the loss of time and information can lead to a significant risk potential for the patients.

Interfaces

Interfaces exist between prehospital and hospital care and also within the particular health care stages. Therefore, future concepts of process optimization in trauma management should contribute to a reduction of interfaces.

Treatment concept

In the treatment of the most severely injured patients, the time factor is crucial. From the prehospital phase and the emergency room to the first surgery phase or the intensive care unit and rehabilitation phase, the treatment concept should take this into account. Interfaces in the trauma network can be practised by different course concepts. Although many interfaces represent risk factors they are not perceived as such.

Vision

It would be consistent and visionary to reduce interfaces by a fundamental reform within trauma treatment.     

Zeitintervalle während und nach Schockraumversorgung

Background

The prognosis of severely injured patients depends on a rapid diagnosis and early initiation of therapeutic procedures.

Material and methods

To that end a total of 6,927 prospectively documented severely injured patients with an Injury Severity Score (ISS) ≥16 from the Trauma Registry of the German Trauma Society (DGU, 2002–2007) were analyzed with respect to time intervals during emergency trauma treatment.

Results

In cases of indicated emergency surgery the average ±time in the emergency department was 42±34 min, in cases of early surgery 75±41 min and in cases of transfer to the intensive care unit (ICU) 83±43 min, respectively. The time from the last diagnostic procedure until the end of emergency treatment was 12 min (emergency surgery), 26 min (early surgery) and 32 min (ICU), respectively. Level I (78 min) and level II (72 min) trauma centres showed similar mean times in the emergency department while level III trauma centres had a mean time of 86 min. According to this analysis no general correlation between shorter duration of emergency trauma care and reduced mortality could be observed.

Conclusion

The duration of time intervals depends on injury severity, treatment after completion of emergency trauma care and the level of the trauma centre. Time management in emergency trauma care can potentially be optimized after completion of the last diagnostic procedure in the emergency room.     

Management von Kombinationsfrakturen des Femurschafts und des proximalen Femurs

Purpose

The combination of ipsilateral femoral neck and shaft fractures remains a treatment challenge in orthopedic surgery because both fracture types constitute separate entities and require specific treatment concepts.

Material and methods

In a case control study, incidence, treatment strategies, and outcomes of this injury were analyzed. All patients with femoral fractures treated between 1 January 2001 and 31 July 2007 at a level I trauma center were included in the study.

Results

Twenty-one out of 1,935 patients (1.1%) sustained 22 combined fractures of the femoral neck and shaft. Also considering the combination of femoral shaft fractures with fractures of the acetabulum and the distal femur (knee), the proportion of chain injuries of the femur was 3.1%. The rate of multiply injured patients in the group of patients with ipsilateral femoral neck and shaft fractures was 64%. The majority of the patients could be treated with a single implant for both fracture components. The leading fracture component was the femoral neck fracture in eight cases. All fractures consolidated after 4.7 months on average; one pseudarthrosis of the femoral neck was observed. All fractures were discovered in the course of primary diagnostic measures; in 73% of the patients, a computed tomography (CT) body scan was done. Fifty-nine percent of the patients with ipsilateral femoral neck and shaft fractures received primary definitive operative care. Complications included two torsional failures that needed correction and one case of postoperative infection that was easily treated.

Conclusion

Treatment of ipsilateral femoral neck and shaft fractures is still demanding, but diagnosis has improved with regular use of CT body scans in the management of multiply injured patients. Furthermore, possibilities for operative treatment have been advanced by the introduction of the long proximal femoral nail and the antegrade femoral nail, two implants supporting stabilization of these fracture entities.     

Die Bedeutung von verzögert diagnostizierten Läsionen bei Polytraumatisierten

Background

Multislice computed tomography (CT) technology has improved the diagnosis of relevant lesions within the phase of primary treatment of severely injured patients. The lack of time in this phase and the complexity of the multiple injuries there is still a risk that lesions will be missed at this stage. The purpose of this study was to evaluate the incidence, causes, implications and significance when injuries are not diagnosed until later.

Methods

The data were documented prospectively in the context of a quality management system for the care of severely injured patients in a primary urban trauma centre. Missed injuries were defined as any lesions that had not been recognised by the time the patient was admitted to the ICU.

Results

During a 44-month period 1,187 (ISS 21±17) patients were enrolled in the study, all of whom were admitted from May 1998 to April 2002 after attending the emergency room. In total 64 (4.9%) missed injuries were detected in 58 (ISS 30±16) patients; 26 of the 64 missed injuries were located on the torso, 8 injuries in the head and neck region, and 30 on the arms and legs. The missed injuries were categorised as follows:

1. Lesion not seen in diagnostics (n=15)
2. Incomplete diagnostics (n=8)
3. Primarily unsuspicious examination (n=35)
4. Diagnostics interrupted due to hemodynamic instability (n=6)

Conclusion

Despite intensified and standardised diagnostic procedures prescribed for use in trauma centres, injuries are still missed in severely injured patients. About 30% of lesions that are not diagnosed until after the patient has left the emergency room have clinically significant, but not lethal, consequences for the patient. Great importance attaches to the follow-up investigation on the intensive care station, so that lesions that have initially been overlooked can be diagnosed and treated as soon as possible so as to keep the complication rate low.     

Traumatische Reanimation nach Überrolltrauma

Background

Decompression of tension pneumothorax and mechanical stabilization of unstable pelvic fractures are simple and potentially life-saving measures. However, these measures are currently not carried out regularly in the emergency medical care of severely injured patients. Although bilateral chest decompression is recommended prior to termination of traumatic resuscitation efforts, this technique has only sporadically found its way into the treatment of traumatic cardiocirculatory arrest.

Case report

We report on a 66-year-old female cyclist who was run over by a wheel loader. She sustained polytrauma with tension hemopneumothorax and died at the scene. On forensic examination at the accident site, massive subcutaneous tissue emphysema ? in the absence of apparent severe injuries ? after 30-min unsuccessful resuscitation attempts and an unstable pelvic ring were determined. Autopsy confirmed death by polytrauma with tension hemopneumothorax and severe internal injuries. The possibility of decompression of the pleural cavity by chest drains, mini-thoracotomy, or thoracic puncture pressure relief before terminating traumatic resuscitation efforts should be included in the management regime for severe trauma patients.     

The “Innsbruck Emergency Algorithm” avoids the underdiagnosis of blunt cervical vascular injuries

Objectives

Blunt cervical vascular injuries (BCVI) from alpine sports accidents bear an increased risk for being underdiagnosed during initial radiological evaluation. At our hospital, the “Innsbruck Emergency Algorithm”, which includes assessment of the neck as a computed tomography (CT) angiography during initial whole-body CT, has been introduced to avoid misdiagnoses and optimizes emergency radiology management.

Methods

Critically injured patients who were admitted for emergency CT after trauma from alpine skiing and mountain-biking accidents and who were reported with BCVI were included in this retrospective study.

Results

During 2003–2009, 36 victims were eligible for inclusion. They presented with a mean (SD) of 4.6 (2.1) diagnoses per patient, of which 3.5 (2.3) were perceptible on radiology examinations only. The “Innsbruck Emergency Algorithm” was performed in 15 individuals while 21 underwent another CT protocol including a native scan of the neck or during a parenchymatous contrast-medium phase only. In addition to BCVI, most patients (71%) were diagnosed with fractures followed by unspecific contusion/s (54%), head injuries (43%), and injuries of parenchymatous organs (19%). In five (14%), BCVI was underdiagnosed during the initial radiological examination. All of the latter had CT during a parenchymatous contrast-medium phase and not according to the “Innsbruck Emergency Algorithm”. Four of those patients died during their hospital stay. In 11, cerebral follow-up examinations showed cerebral pathologies considered as results from BCVI.

Conclusions

The “Innsbruck Emergency Algorithm” in patients with clinically unapparent BCVI after skiing and mountain-biking accidents avoided overlooking vascular injuries, which significantly improved their long-term outcome.     

Karpale Begleitläsionen bei dislozierter distaler Radiusfraktur

Background

The functional outcome of surgically treated dislocated fractures of the distal radius is limited and does not correlate with radiographic results. Additional carpal lesions are assumed to be the cause. This study has evaluated which carpal lesions are associated with dislocated fractures of the distal radius.

Material and methods

A total of 104 consecutive patients with dislocated fractures of the distal radius were included in the study. The injured wrist was examined by radiography, computed tomography (CT) and magnetic resonance imaging (MRI) to determine additional carpal lesions.

Results

Radiographically 51 of the 104 fractures presented as type A according to the AO classification, 10 as type B and 39 as type C. The CT scan detected that only 5 of the 51 type A fractures were exclusively metaphyseal fractures. All type A fractures were associated with ligamental lesions in MRI.

Conclusions

The results of the study confirm the hypothesis that every dislocated fracture of the distal radius is a combined carpal trauma associated with additional osseous and/or ligamental lesions.     

The incidence and the risk factors of venous thromboembolism in Korean patients with pelvic or acetabular fractures

Background

Pelvic ring and acetabular fractures are the results of high energy trauma, but there is a paucity of information available regarding the incidence and risk factors of venous thromboembolism (VTE) after these injuries in Asians. This study was undertaken to evaluate the incidence of VTE after a pelvic or an acetabular fracture and to identify predictive factors.

Methods

A prospective evaluation was performed by indirect computed tomography (CT) venography in patients with pelvic or acetabular fractures. Ninety-five patients were examined by indirect CT venography. Fifty-five patients suffered from a pelvic ring injury (anteroposterior compression 5, lateral compression 25, vertical shear 25), and the remaining 40 from acetabular fractures (simple 18, complex 22). Indirect CT venography was performed within 1–2 weeks of initial trauma. Relationships between VTE and sex, age, fracture pattern, body mass index, injury severity score, period of immobilization, and need for surgical treatment were analyzed. Deep vein thrombosis (DVT) in a more proximal to popliteal vein and the existence of PE were considered clinically significant.

Results

Thirty-two patients (33.7 %) were found to have VTE at an average of 11 days after initial injury. Clinically significant DVT was found 20 cases (21.1 %). No statistical difference was found between pelvic ring injuries and acetabular fractures with respect to the development of VTE. For those with pelvic ring injury, the incidence of VTE in those with a vertical shear injury (52 %) was significantly greater than in others with a pelvic ring injury (p = 0.014). Patients with an age >50 were found to be at greater risk of VTE (p = 0.032).

Conclusion

Our findings demonstrate that Korean patients with pelvic or acetabular fractures have a higher risk of VTE than is generally believed, and caution should be taken to prevent and treat VTE, especially in high energy pelvic ring injury and elderly patients.     

Detecting active pelvic arterial haemorrhage on admission following serious pelvic fracture in multiple trauma patients

Background

The early diagnosis of pelvic arterial haemorrhage is challenging for initiating treatment by transcatheter arterial embolization (TAE) in multiple trauma patients. We use an institutional algorithm focusing on haemodynamic status on admission and on a whole-body CT scan in stabilized patients to screen patients requiring TAE. This study aimed to assess the effectiveness of this approach.

Methods

This retrospective cohort study included 106 multiple trauma patients admitted to the emergency room with serious pelvic fracture [pelvic abbreviated injury scale (AIS) score of 3 or more].

Results

Of the 106 patients, 27 (25%) underwent pelvic angiography leading to TAE for active arterial haemorrhage in 24. The TAE procedure was successful within 3 h of arrival in 18 patients. In accordance with the algorithm, 10 patients were directly admitted to the angiography unit (n = 8) and/or operating room (n = 2) for uncontrolled haemorrhagic shock on admission. Of the remaining 96 stabilized patients, 20 had contrast media extravasation on pelvic CT scan that prompted pelvic angiography in 16 patients leading to TAE in 14. One patient underwent a pelvic angiography despite showing no contrast media extravasation on pelvic CT scan. All 17 stabilized patients who underwent pelvic angiography presented a more severely compromised haemodynamic status on admission, and they required more blood products during their initial management than the 79 patients who did not undergo pelvic angiography. The incidence of unstable pelvic fractures was however comparable between the two groups. Overall, haemodynamic instability and contrast media extravasation on the CT-scan identified 26 out of the 27 patients who required subsequent pelvic angiography leading to TAE in 24.

Conclusions

An algorithm focusing on haemodynamic status on arrival and on the whole-body CT scan in stabilized patients may be effective at triaging multiple trauma patients with serious pelvic fractures.     

Der Schockraum – Diagnostik-, Therapie- und Managementzentrale

Background:

In the treatment of the polytraumatized patient ,time is crucial. New technical developments such as multislice CT, which can finish the polytrauma spiral in 90–240 s, shorten the duration of trauma treatment considerably. In the past, CT diagnostics have been used after the initial diagnostics.

Methods:

To obtain the full advantage of the new multislice CT, it is important to put carry out CT diagnostics in the first minutes of clinical care. After the installation of a multislice CT in the emergency room, we developed an algorithm in which CT diagnostics are made in these first minutes.

Results:

The new algorithm was performed on 118 patients. At 8 min (±5,7 SD) after the patient’s arrival CT was started. It was completed 13 min (±8,4 SD) after the arrival of the patient. The time in the emergency room decreased from 87 min to 38 min (±19,1 SD).

Conclusions:

Early CT diagnostics can save time for the trauma patient, with life threading injuries being recognized within minutes.     

Multislice-Spiral-CT zur Diagnostik beim Polytrauma

Background

In severely injured patients, diagnostic procedures should be as brief as possible. With the use of spiral CT technology, the time required for diagnosis is minimized.

Question

Do severely injured patients benefit when primary diagnostic examinations are completed in less than 30 min? How much time is required for primary emergency department (ED) care and how much in the CT scanner?

Material and methods

Between 31 July 2001 and 31 December 2003, severely injured patients with ISS scores over 16 underwent total body spiral CT scans (Siemens Somatom Volume Zoom Multislice CT) after initial ultrasonography. One hundred patients (M:F=25:75) with an average age of 42 years (range: 3–81 years) were evaluated retrospectively. The average ISS score was 32.8±12 points (range: 17–75 points).

Results

The average time in the ED, prior to CT, was 33±14 min. The CT scans lasted 16±5 min and the total diagnostic time was 48±14 min. Fifty percent of patients were taken immediately to the operating room. The mortality rate in hospital was 13%. The average hospital stay was 30 days, with an average ICU stay of 10 days.

Conclusion

The shorter the time spent in the ED, the shorter the stays in ICU and in total hospitalization were, regardless of injury severity. With structured management and shortening of diagnostic time with spiral CT, the time in the ED was decreased from 85 to 48 min.     

Organisatorische, personelle und strukturelle Ver?nderungen durch die Teilnahme am TraumaNetzwerkD DGU

Background

By implementation of a nationwide trauma network in Germany a high quality standard of technical, personnel and scientific conditions should be attained in hospitals participating in care for severely injured patients. All hospitals audited within the framework of TraumaNetwork^D DGU are also evaluated for the modifications undertaken by answering a questionnaire. Using this data it was possible to 1) obtain information about hitherto existing personnel and technical infrastructures of all participating hospitals and 2) to present first positive effects achieved by implementation and participating in TraumaNetwork^D DGU.

Materials and methods

The questionnaire contained 41 questions concerning organizational, personnel and structural changes to justify the motivation for participating in TraumaNetwork^D DGU and regarding the degree of confidence with reference to the work of the AKUT office. Analysis of data has been carried out and given as a percentage of all useable questionnaires.

Results

Data of 138 hospitals has been evaluated. Regarding organizational changes 29% of national/supraregional trauma centers made fewer adjustments than local (44%) and regional (55%) trauma centers. Personnel changes mainly affected participation in ATLS courses, cooperation with a neurosurgical department and reorganization of work schedules. With respect to structural changes most frequently emergency operating sets for emergency surgery have been established, teleradiology systems have been implemented and in 25% of the cases a sonography unit has been acquired. The rarest, but also most cost-intensive, new acquisition has been a CT scanner in or close to the emergency trauma room (10%). The work of the AKUT office has been rated altogether more satisfying by local trauma centers (mean 2.4) than by regional and national trauma centers (mean 2.6). Prompt information by AKUT has been especially praised (mean 2.1).

Conclusion

Being organized in trauma networks motivates hospitals to optimize their operational sequences and personnel and structural conditions. How much the care for multiple injured patients can be improved nationwide in Germany will be shown over the next few years. Through compulsive participation in TraumaRegister^QM DGU (quality management) as a measurement for quality assurance this will be analyzed and evaluated scientifically.     

Interventionelle Notfallembolisation bei schweren Beckenfrakturen mit arterieller Blutung

Objective

Presentation of our own experiences and results of an early clinical algorithm for treatment integrating emergency embolization (TAE) in cases of unstable pelvic ring fractures with arterial bleeding.

Method

Consecutive patient series from April 2002 to December 2006 at a level 1 trauma center. The data of the online shock room documentation (Traumawatch®) of patients with a pelvic fracture and arterial bleeding detected on multislice computed tomography (MSCT) were examined for the following parameters: demographic data, injury mechanism, fracture classification according to Tile/AO and severity of the pelvic injury assessed with the Abbreviated Injury Score (AIS), accompanying injuries with elevation of the cumulative injury severity according to the Injury Severity Score (ISS), physiological admission parameters (circulatory parameters and initial Hb value) as well as transfusion requirement during treatment in the shock room, time until embolization, duration of embolization, and source of bleeding.

Results

Of a total of 162 patients, arterial bleeding was detected in 21 patients by contrast medium extravasation on MSCT, 12 of whom were men and 9 women with an average age of 45 (14–80) years. The mechanism of injury was high energy trauma in all cases. In 33% it involved type B pelvic fractures and in 67% type C fractures with an average AIS pelvis of 4.4 points (3–5) and a total severity of injury with the ISS of 37 points (21–66). Upon admission 47.6% presented hemodynamic instability with an average Hb value of 7.8 g/dl (3.2–12.4) and an average transfusion requirement of 6 red blood cell units (4–13). The time until the TAE was started was on average 62 min (25–115) with a duration period of the TAE of 25 min (15–67). Branches of the internal iliac artery were identified as the sole source of bleeding. The success rate of TAE amounted to over 90%.

Conclusion

Interventional TAE represents an effective as well as a fast procedure for hemostasis of arterial bleeding detected on MSCT in patients with pelvic fractures. If an experienced radiologist on 24-h stand-by is assured and the infrastructure is efficient, this can be performed shortly after hospital admission and therefore should be integrated into the early clinical treatment protocol.     

Bonner Schockraummanagement-Kurs®

Backround

Intrahospital acute care of the severely injured patient is guided by interprofessional and interdisciplinary procedures. A grade A recommendation by the current S3 guidelines for the management and treatment of severely injured patients requires that established teams – so-called emergency room teams – treat patients according to prestructured management plans and/or should undergo a specific training.

Methods

The University Hospital Bonn is a level I trauma center and has implemented these guidelines by establishing the Bonner Schockraummanagement course®. The following objectives should be accomplished for the interprofessional and interdisciplinary treatment and management of the severely injured patient adapted to realistic scenarios and conditions: integration of all trauma-involved professions including prehospital care units in a training according to S3 guidelines with best possible evidence, Human Factor Training and modern educational modalities and concepts integrated into clinical daily routine. The course was introduced as a blended learning concept which is facilitated by a student’s course manual based on the guidelines and training videos which can be used as home educational tools. Oral presentations during the course and full-scale simulator team training with real life scenarios build the core of the educational concept. Each scenario is followed by a debriefing focusing on the horizontal approach of trauma care and human factor training. Continuous scientific course evaluation provides a base for further improvements.

Conclusion

The Bonner Schockraummanagement course® represents a symbiosis of horizontal approach of trauma care and human factor training. Thus, acute care of the severely injured patient will improve by integrating all associated professions and disciplines in a focused team training.     

A national survey of United Kingdom trauma units on the use of pelvic binders

Purpose

Major pelvic injuries resulting from high-energy trauma require emergency hospital treatment, and part of the initial management includes mechanical stabilisation of the pelvis. Controversies include binder position, use in lateral compression injuries and application during radiological assessment. We present the results of a survey of both emergency department and orthopaedic specialties.

Methods

A telephone survey of all 144 trauma units in the UK accepting adult pelvic trauma patients was carried out in July 2012. The duty registrar for the emergency and orthopaedic departments was contacted and asked to complete a questionnaire.

Results

A response rate of 100 % was achieved. Pelvic binders were available for use in approximately three quarters of the trauma units surveyed. Eight-five emergency department (59 %) and 79 orthopaedic (54.9 %) registrars had been given training on pelvic binder application. Fifty-six emergency department (38.9 %) and 114 orthopaedic (79.1 %) registrars identified the level of the greater trochanters as the most suitable position for the binder. Forty-five emergency department (31.3 %) and 58 orthopaedic (40.3 %) registrars used pelvic binders in suspected lateral compression injuries. One hundred and twenty-six emergency department (87.5 %) and 113 orthopaedic (78.5 %) registrars would not release the binder during radiological assessment of the pelvis in a haemodynamically stable patient.

Conclusion

There is great variability in practice amongst trauma units in the UK. Training must be formalised and provided as a mandatory part of departmental induction. The use of standardised treatment algorithms in trauma units and the Advanced Trauma and Life Support (ATLS) framework may help decision making and improve patient survival rates.     

Beckenringinstabilitäten

Background

Pelvic ring injuries occur in patients aged 20–30 years old after high energy trauma and also in patients over the age of 65 years predominantly after low energy trauma. The latter have greatly increased. The necessity for treatment depends on the degree of instability and on the accompanying injuries and comorbidities.

Emergency treatment

Despite following effective treatment algorithms, pelvic ring injuries caused by high energy force still have a high mortality rate. The differentiation between pelvic ring fractures with or without life-threatening bleeding is extremely important in the initial phase of treatment of these patients. The emergency treatment of life-threatening pelvic ring fractures should be embedded in a standardized protocol for the treatment of severely injured patients. Among the first measures are external stabilization, such as pelvic ferrules and external fixators as well as surgical hemostasis of the lesser pelvis. The final osteosynthesis should be performed in the secondary phase when the patient shows stable vital signs.

Elective treatment

A pelvic ring fracture without relevant circulatory instability can be electively treated after completion of clinical diagnostics. Type A injuries are predominantly conservatively treated. In type B injuries stabilization of the anterior pelvic ring via osteosynthesis of the symphysis or external fixator is sufficient. The restoration of stability of the dorsal pelvic ring is the main task in type C injuries. Sacral fractures are a special feature. In cases of neurological disorders these fractures need immediate osteosynthesis after decompression of the neural structures. Highly unstable injuries require spinopelvic stabilization.

Results

The outcome of patients depends on the extent of the injuries suffered and on the quality of repositioning and stabilization. The results of radiological investigations were better than the functional outcome.

     

Beckenring- und Apophysenverletzungen im Kindes- und Jugendalter

Background

Pediatric pelvic fractures are rare injuries. Typically they are associated with high-energy trauma, which often leads to life-threatening injuries of other organs. Anatomical differences (e.g., greater elasticity, different stages of maturation, remodeling) account for the different fracture mechanisms, fracture management, and outcome in children. The AO Classification (International Association for Osteosynthesis) is useful and can be used as a basis for the treatment algorithm in pediatric pelvic fractures.

Aim

This article provides a review on pediatric pelvic fractures and shows – based on the AO classification – principles of conservative und operative treatment.