[Associated injuries in severe pelvic trauma].
There has been a marked increase in the incidence of pelvic fractures over the last few years. Associated injuries to the urogenital and vascular system as well as nerve injuries worsen the prognosis. Over a five year period 126 patients with severe pelvic trauma were treated. Out of these 39 (30.9%) sustained additional peripelvic injuries and represent the study sample. Type B injuries according to the AO classification occurred in 16 (41%) patients, type C fractures in 23 (59%) patients. The spleen, liver and kidney were the most frequently injured organs (58.9%), followed by urogenital lesions (46.6%), nerve injuries (25.6%) and vascular lesions (15.3%). The most common extrapelvic lesions were thoracic injuries in 56.4% and severe head injuries (GCS < 8) in 33.3%. The mean Hannover Polytrauma score was 35.6 points, the mean Injury Severity Score 27.6 points. Osteosynthesis was performed in 21 pelvic ring fractures (53%), eight procedures (50%) in type B fractures and 13 (56%) in type C fractures. In type B injuries the anterior pelvic ring was stabilized with a tension band wiring in four cases, in two patients with an external fixator and with plate osteosynthesis in one case. In type C injuries the external fixator was applied as the only stabilizing procedure in six patients. In four cases the anterior ring was fixed with tension band wiring or plates and the dorsal aspect of the pelvic ring with sacral bars. Three patients had their additional acetabular fracture plated through a anterior approach. All surviving 28 patients were followed up for an average of 18 months (range 7-59 months) after the trauma. The patients were classified using the pelvic outcome score proposed by the German Society of Trauma Surgery. 53.4% of the type B fractures showed a good clinical outcome, 47.6% a poor outcome. 15.4% with type C fractures presented with a good outcome, 84.6% with a poor outcome. 80% of the type B and 23% of the type C fractures had a good radiological outcome. 20% of type B and 77% of type C injuries had a poor radiological outcome. Five patients (12.8%) sustained persistent urological symptoms. Three of these had urinary dysfunction, two used permanent cystotomies due to their severe neurological deficit after a head injury. Ten patients with nerve injuries at the time of trauma suffered long term neurological dysfunction of the lumbosacral plexus. The mortality rate was 28%. Seven patients died in the emergency room due to uncontrollable bleeding, four in the intensive care unit from multi-organ failure. The management of complex pelvic trauma consists of fracture treatment and interdisciplinary treatment of the associated injury. Lesions of the abdominal organs or of major vessels must be addressed first if hemodynamic instability is present. Injuries to smaller vessels can be embolized percutaneously. Urinary bladder ruptures are treated as an emergency, urethral lesions electively after four to six weeks. We recommend external fixation of the pelvis in the acute phase for control of both the osseous instability and control of haemorrhage through external compression. The treatment of choice for the anterior pelvic ring is tension band wiring or plating. If this is contraindicated due to an open fracture external fixation is the treatment of choice. Type C fractures require posterior ring stabilization which should be postponed until four days post admission.