Fractures of the pelvic ring are comparatively rare with an incidence of 2-8 % of all fractures depending on the study in question. The severity of pelvic ring fractures can be very different ranging from simple and mostly "harmless" type A fractures up to life-threatening complex type C fractures. Although it was previously postulated that high-energy trauma was necessary to induce a pelvic ring fracture, over the past decades it became more and more evident, not least from data in the pelvic trauma registry of the German Society for Trauma Surgery (DGU), that low-energy minor trauma can also cause pelvic ring fractures of osteoporotic bone and in a rapidly increasing population of geriatric patients insufficiency fractures of the pelvic ring are nowadays observed with no preceding trauma.Even in large trauma centers the number of patients with pelvic ring fractures is mostly insufficient to perform valid and sufficiently powerful monocentric studies on epidemiological, diagnostic or therapeutic issues. For this reason, in 1991 the first and still the only registry worldwide for the documentation and evaluation of pelvic ring fractures was introduced by the Working Group Pelvis (AG Becken) of the DGU. Originally, the main objectives of the documentation were epidemiological and diagnostic issues; however, in the course of time it developed into an increasingly expanding dataset with comprehensive parameters on injury patterns, operative and conservative therapy regimens and short-term and long-term outcome of patients. Originally starting with 10 institutions, in the meantime more than 30 hospitals in Germany and other European countries participate in the documentation of data. In the third phase of the registry alone, which was started in 2004, data from approximately 15,000 patients with pelvic ring and acetabular fractures were documented. In addition to the scientific impact of the pelvic trauma registry, which is reflected in the numerous national and international publications, the dramatically changing epidemiology of pelvic ring fractures, further developments in diagnostics and the changes in operative procedures over time could be demonstrated. Last but not least the now well-established diagnostic and therapeutic algorithms for pelvic ring fractures, which could be derived from the information collated in registry studies, reflect the clinical impact of the registry.

BACKGROUND:Complex pelvic traumas, i.e., pelvic fractures accompanied by pelvic soft tissue injuries, still have an unacceptably high mortality rate of about 18 %. PATIENTS AND METHODS:We retrospectively evaluated an intersection set of data from the TraumaRegister DGU® and the German Pelvic Injury Register from 2004-2009. Patients with complex and noncomplex pelvic traumas were compared regarding their vital parameters, emergency management, stay in the ICU, and outcome. RESULTS:From a total of 344 patients with pelvic injuries, 21 % of patients had a complex and 79 % a noncomplex trauma. Complex traumas were significantly less likely to survive (16.7 % vs. 5.9 %). Whereas vital parameters and emergency treatment in the preclinical setting did not differ substantially, patients with complex traumas were more often in shock and showed acute traumatic coagulopathy on hospital arrival, which resulted in more fluid volumes and transfusions when compared to patients with noncomplex traumas. Furthermore, patients with complex traumas had more complications and longer ICU stays. CONCLUSION:Prevention of exsanguination and complications like multiple organ dysfunction syndrome still pose a major challenge in the management of complex pelvic traumas.

Komplexe Beckentraumen (KBT), d. h. Beckenfrakturen mit peripelvinen Begleitverletzungen, zeigen bis heute eine hohe Mortalität von etwa 18 %.

Zusammenfassung Der Verletzung des Beckenringes kommt eine hohe Bedeutung im Rahmen eines Polytraumas zu. Der Einsatz differenzierter diagnostischer Verfahren in der Frühphase des Beckentraumas sowie die frühzeitige Stabilisierung dieser Frakturen im Sinne des „damage control“ haben zu nachhaltigen Verbesserungen in der Behandlung geführt. Dies gilt insbesondere für die Gruppe älterer Patienten, die zahlenmäßig zunehmen und aktuell im Fokus der Weiterentwicklungen von Behandlungsregimen stehen. Nach wie vor besteht eine erhöhte Mortalität bei Patienten mit Beckenringfrakturen, insbesondere bei polytraumatisierten Patienten. Sowohl die Standardisierung des Notfallmanagements im Schockraum als auch die sinnvolle Erweiterung und Anwendung neuer „tools“ in der Präklinik tragen dazu bei, die Behandlungsoptionen ständig weiterzuentwickeln. Da aber auch die längerfristigen Probleme nach der Versorgung instabiler Beckenringfrakturen weiterhin problematisch bleiben, müssen die notwendigen Behandlungsverfahren weiterhin regelmäßig den Anforderungen angepasst werden.

Abstract Background. Complex pelvic traumas, i.e., pelvic fractures accompanied by pelvic soft tissue injuries, still have an unacceptably high mortality rate of about 18%.Patients and methods. We retrospectively evaluated an intersection set of data from the TraumaRegister DGU® and the German Pel-vicInjuryRegisterfrom2004–2009.Patientswith complex and noncomplex pelvic trau-mas were compared regarding their vital pa-rameters, emergency management, stay in the ICU, and outcome.Results. From a total of 344 patients with pelvicinjuries,21%ofpatientshadacom-plex and 79% a noncomplex trauma. Com-plex traumas were significantly less likely to survive (16.7% vs. 5.9%). Whereas vital pa-rameters and emergency treatment in the preclinical setting did not differ substantial-ly, patients with complex traumas were more often in shock and showed acute traumat-ic coagulopathy on hospital arrival, which re-sulted in more fluid volumes and transfu-sions when compared to patients with non-complex traumas. Furthermore, patients with complex traumas had more complications andlongerICUstays.Conclusion. Prevention of exsanguination and complications like multiple organ dys-function syndrome still pose a major chal-lenge in the management of complex pel-vic traumas.

Pelvic injuries are often associated with multiple injuries of other body regions, neurovascular and visceral lesions, as well as hemodynamic instability. The use of a standardized classification characterizing the severity and stability of pelvic fractures and the early stabilization of pelvic ring injuries in appreciation of damage control principles has helped to improve the number of survivors. This is particularly necessary due to the higher number of older patients.Complex pelvic trauma still represents a life-threatening situation for the patient, particularly in multiple traumatized patients. Standardized clinical investigations and modern concepts even in the preclinical therapy of complex pelvic fractures make a contribution to enhancement of treatment options. Because of the still problematic long-term results after surgery of instable pelvic fractures, the need for modern treatment concepts has to be adapted to the requirements.

Die differenzierte Therapie von Azetabulumfrakturen ist mittlerweile ein Spezialgebiet der Unfallchirurgie. Basierend auf den grundlegenden Untersuchungen von Letournel und später Matta konnte eine ganz wesentliche Standardisierung von Diagnostik, Klassifikation, Entscheidungsfindung sowie operativen Möglichkeiten bei diesen Verletzungen erreicht werden. Da eine exakte Wiederherstellung der anatomischen Gelenkgeometrie für die behinderungsfreie Ausheilung essenziell ist, ist die exakte Kenntnis der Verfahrensweise zur Diagnostik, der Interpretation der bildgebenden Verfahren sowie der Frakturklassifikation notwendig, um eine hochqualitative Versorgung, ggf. auch Entscheidungsfindung zur Weiterverlegung in ein Spezialzentrum, zu gewährleisten. Aufgrund der immer älter werdenden Bevölkerung stellen Azetabulumfrakturen bei Patienten mit verminderter Knochenqualität ein zunehmendes Problem dar. Während diese Fälle noch vor 20 Jahren als Kontraindikation für eine operative Therapie galten, kann durch modifizierte Techniken inzwischen auch in der Altersgruppe über 65 Jahre in etwa 80% der Fälle ein gutes Langzeitergebnis durch Gelenkrekonstruktion erreicht werden.

The aim of this study was to analyze the clinical outcome and incidence of hip arthritis in elderly patients with acetabular fractures. Because of poor bone quality in the elderly, even a low-energy trauma may lead to an acetabular fracture. An anatomical reconstruction of the acetabulum is necessary to achieve sufficient stability also for a potential hip arthroplasty. So far, there is very limited information on the outcome of acetabular fractures in the elderly.During a period of 6 years (2001-2006), 48 patients older than 60 years were admitted to our department with an acetabular fracture. Thirty-nine patients were treated operatively and nine patients non-operatively. Twenty-nine operatively treated patients were followed up. Nineteen of them were assessed using EQ-5D, SF-12 and Merle d'Aubign, questionnaires in addition to their clinical examination. Ten other surgical patients were only examined using the questionnaires. Of the 29 patients that were followed up, 5 underwent total hip arthroplasty due to secondary post-traumatic hip arthritis after open reduction and internal fixation (ORIF). The range of motion of the operated hip was comparable to that of the non-operated contralateral side. However, the internal rotation was found to be slightly decreased at the operated side when compared to the non-operated contralateral side. Merle d'Aubign, score and physical and mental SF-12 score components as well as quality of life were better in patients treated with ORIF compared to those patients that were treated by secondary hip arthroplasty.Regarding the different treatment strategies (ORIF vs primary hip arthroplasty vs non-operative treatment) of acetabular fractures in the elderly, data from the literature are conflicting. Our results indicate that ORIF represents a good treatment option for acetabular fractures in the elderly. In patients that did not develop secondary hip arthritis, a good clinical outcome and quality of life was documented.

Durch die Definition des Komplextraumas bei Beckenverletzungen ist es gelungen, die bzgl. der Überlebensrate kritischen Patienten klar zu selektieren. Komplexe Beckenfrakturen sind Verletzungen des Beckenrings, die mit zusätzlich begleitenden peripelvinen Verletzungen assoziiert sind. Diese umfassen Verletzungen der Weichteile (Haut-Muskel), des Urogenital- und Darmtrakts, der großen Nervenbahnen und Verletzungen von Arterien, Venen und Venengeflechten im kleinen Becken. Komplexverletzungen des Beckens sind trotz Verbesserung der klinischen Erstversorgung weiterhin mit einer hohen Letalität vergesellschaftet. Insbesondere bei einer begleitenden Gefäßverletzung und dadurch bedingter hämodynamischer Instabilität steigt die Letalität deutlich an. Die maximale Ausprägung des komplexen Beckentraumas ist die Hemipelvektomie, die mit einer Letalität bis 60% assoziiert ist.

Während Beckenringverletzungen bei jüngeren Patienten zwischen dem 2. und 3. Lebensjahrzehnt typischerweise infolge eines Hochrasanztraumas auftreten, zeigt sich ein zweiter deutlicher Gipfel im höheren Lebensalter zwischen dem 7. und 8. Lebensjahrzehnt. Hier ist insbesondere das weibliche Geschlecht betroffen, die notwendige einwirkende Verletzungsenergie ist bei häufig gestörter Knochenstruktur (Osteoporose, Komorbidität) dabei wesentlich geringer. Nach der Anamneseerhebung zum Unfallhergang schließt sich eine klinische Untersuchung des Beckens an. Anschließend kommen bildgebende Verfahren mit konventionellen Röntgenuntersuchungen und CT mit ggf. 3D-Rekonstruktionen zum Einsatz. Bei Begleitverletzungen werden zusätzlich weitere diagnostische Maßnahmen erforderlich (Sonographie, „nuclear magnetic resonance“ – NMR, retrograde Uretrographie, Zystogramm, Ausscheidungsurogramm).

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.

The definition of complex pelvic trauma has allowed a selection of those pelvic fracture patients with the highest mortality rate. The term complex pelvic trauma is used as a definition for pelvic fractures which are associated with serious soft tissue lesions in the pelvic region. These may include visceral and neurovascular, as well as extensive skin and muscle injuries. Haemodynamic instability particularly related to vascular injuries raises the mortality dramatically. Traumatic hemipelvectomy, which represents the worst case of a complex pelvic trauma, is associated with mortality rates of up to 60%. The pelvic study groups 1-3 of the German trauma association (DGU) and the Association for Osteosynthesis (AO) provide the worldwide largest database on pelvic injuries (group 1, 1991-1993: 1,722 patients from 10 hospitals; group 2, 1998-2002: 2,569 patients from 22 hospitals; and group 3, 2005-2007: 2,704 patients from 23 hospitals). Using this database this article reviews epidemiological data, therapy concepts, associated injuries as well as the incidence and mortality rates related to complex pelvic trauma over a 16-year time period. Special attention has been paid to complex trauma in the elderly (patients > 60 years of age). An additional aim of this article is to analyze the correlation between different treatment modalities and the mortality rate of complex pelvic trauma and to investigate whether changes in the treatment of complex pelvic trauma have improved the outcome of these injuries. Taken together an increase in measures for an initial mechanical stabilization of the pelvic ring, such as the use of the pelvic C clamp, the external fixator or primary osteosynthesis was found over the 16-year observation period. In addition to stabilization of the pelvic ring, pelvic tamponade for mechanical haemostasis has been proven to be one of the most effective measures to control haemorrhaging. These treatment regimes did not differ between young patients and patients > 60 years of age. Regarding the outcome of these treatment strategies only slight decreases in the mortality rate were found (pelvic study group 1: 21%; pelvic study group 2: 22%; pelvic study group 3: 18%). In all pelvic study groups the mortality rate in patients > 60 years of age was found to be significantly higher than in individuals < 60 years of age (pelvic study group 1: 57% versus 29.6%, pelvic study group 2: 33% versus 22.6%, pelvic study group 3: 41% versus 10.4%, p < 0.05, respectively).

The diagnosis and treatment of pelvic ring injuries is demanding. Therefore, standardized classifications characterizing the stability and severity of pelvic ring fractures are essential to define clear algorisms for the treatment of these injuries. The first part of this article provides an overview of the etiology and classification of pelvic ring injuries. We recommend the AO classification to assess the stability of pelvic ring fractures. This classification includes 3 types of pelvic ring fractures: stable fractures (type A), fractures with only rotational instability (type B), and fractures with complete (rotational and translational) instability. To describe the severity of the injury, pelvic ring fractures can be classified as plain pelvic fractures, which include fractures with osteoligamentous instability, but without significant concomitant injuries to the soft tissue, versus complex pelvic fractures, which are combined with severe peripelvic soft tissue lesions. While plain pelvic fractures allow thorough clinical and radiological diagnostics, complex pelvic traumata represent a life threatening situation for the patient, which needs immediate emergency measures.In the second part of the this review we present current data of the German Pelvic Multicenter Study III (DGU/AO) on the epidemiology and treatment of pelvic ring injuries deriving from a study population of more than 3000 patients. In addition, we compare the present data with those of the German Pelvic Multicenter Study I and highlight changes in the epidemiology and treatment of pelvic ring fractures during the past decades. Taken together, we could observe an increasing number of elderly patients sustaining pelvic ring fractures. Regarding the treatment of pelvic ring fractures we found a rising use of external fixators and SI screws, while the number of laparotomies has markedly decreased.