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Die Beckenringzerreißung beim polytraumatisierten Patienten

Pelvic injuries in the polytraumatized patient

  • Leitthema
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Zusammenfassung

Die Behandlung der Beckenringzerreißung stellt aufgrund ihrer lebensbedrohlichen lokalen Begleitverletzungen eine permanente Herausforderung in der Versorgung polytraumatisierter Patienten dar und beeinflusst wesentlich deren Prognose.

Beckenringverletzungen sind mit einem Anteil von 3–8% aller Frakturen seltene Verletzungen. Allerdings steigt die Inzidenz bei mehrfachverletzten Patienten auf 25% an. In der initialen Behandlung des mehrfachverletzten Patienten mit Beckenringverletzung ist die schnelle Erkennung vital bedrohlicher Verletzungen (Massenblutung, Hohlorganverletzung, offene Beckenringzerreißung, Hemipelvektomie) und ein kompromissloses operatives Vorgehen („damage control“) entscheidend. Instabile Beckenringverletzungen sind häufig mit anderen schweren Begleitverletzungen (Schädel-Hirn-Trauma, Abdominaltrauma, Wirbelsäulenverletzung) kombiniert, die die Letalität (20–35%) wesentlich beeinflussen können.

Die Diagnostik und das Management der Beckenringverletzung richtet sich beim mehrfachverletzten Patienten primär nach der hämodynamischen Situation des Patienten und dem Vorliegen von Schädel-Hirn- und Torsoverletzungen. Die Techniken und der Zeitpunkt für die definitive Stabilisierung des Beckenrings können sich beim Polytrauma aufgrund der Begleitverletzungen von der Versorgung der isolierten Beckenringverletzung unterscheiden.

Abstract

Pelvic injuries represent a thorny and stubborn therapeutic challenge. Because major forces are required to fracture the pelvis, pelvic ring disruption, more than any other fracture, can lead to life-threatening associated injuries such as massive bleeding, organ injuries, and open fractures including hemipelvectomy.

The rapid diagnosis and effective treatment (“damage control”) of those injuries play the key role in the patient’s survival, inasmuch as the mortality of multiply injured patients with pelvic ring disruption remains high with 20–35%. Exsanguinating hemorrhage represents the most dreaded acute complication of pelvic injuries.

Therefore, diagnostic and therapeutic procedures have to be primarily adapted to the hemodynamics of the patient, secondarily to injuries of the brain and the torso. The time point and the techniques of definitive pelvic ring stabilization may be different in the patient with multiple injuries compared to isolated pelvic ring injuries.

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Literatur

  1. Advanced Trauma Life Support for Doctors (2004) ATLS. American College of Surgeons, Committee on Trauma, Chicago, IL

  2. Adams JE, Davis GG, Alexander CB, Alonso JE (2003) Pelvic trauma in rapidly fatal motor vehicle accidents. J Orthop Trauma 17: 406–410

    Article  PubMed  Google Scholar 

  3. Adams JE, Davis GG, Heidepriem RW 3rd, Alonso JE, Alexander CB (2002) Analysis of the incidence of pelvic trauma in fatal automobile accidents. Am J Forensic Med Pathol 23: 132–136

    Article  PubMed  Google Scholar 

  4. Albrecht T, von Schlippenbach J, Stahel PF, Ertel W, Wolf KJ (2004) The role of whole body spiral CT in the primary work-up of polytrauma patients — comparison with conventional radiography and abdominal sonography. Rofo 176: 1142–1150

    PubMed  Google Scholar 

  5. Aslar AK, Kuzu MA, Elhan AH, Tanik A, Hengirmen S (2004) Admission lactate level and the APACHE II score are the most useful predictors of prognosis following torso trauma. Injury 35: 746–752

    Article  PubMed  Google Scholar 

  6. Barletta JF, Ahrens CL, Tyburski JG, Wilson RF (2005) A review of recombinant factor VII for refractory bleeding in nonhemophilic trauma patients. J Trauma 58: 646–651

    PubMed  Google Scholar 

  7. Baron BJ, Sinert RH, Sinha AK, Buckley MC, Shaftan GW, Scalea TM (1999) Effects of traditional versus delayed resuscitation on serum lactate and base deficit. Resuscitation 43: 39–46

    Article  PubMed  Google Scholar 

  8. Bartlett C, Asprinio D, Louis S, Helfet D (1997) Intrapelvic dislocation of the left hemipelvis as a complication of the pelvic „C“ clamp: a case report and review. J Orthop Trauma 11: 540–542

    Article  PubMed  Google Scholar 

  9. Bircher M, Hargrove R (2004) Is it possible to classify open fractures of the pelvis. Eur J Trauma 2: 74–79

    Article  Google Scholar 

  10. Bircher MD (1996) Indications and techniques of external fixation of the injured pelvis. Injury 27 ]Suppl 2B]: 3–19

    Article  Google Scholar 

  11. Bosch U, Pohlemann T, Tscherne H (1992) Primary management of pelvic injuries. Orthopade 21: 385–392

    PubMed  Google Scholar 

  12. Dunstan E, Bircher M (2000) Urological pitfalls in unstable pelvic fractures. Injury 31: 379–382

    Article  PubMed  Google Scholar 

  13. Ertel W, Eid K, Keel M, Trentz O (2000) Therapeutical strategies and outcome of polytraumatized patients with pelvic injuries. Eur J Trauma 6: 278–286

    Google Scholar 

  14. Ertel W, Keel M, Eid K, Platz A, Trentz O (2001) Control of severe hemorrhage using C-clamp and pelvic packing in multiply injured patients with pelvic ring disruption. J Orthop Trauma 15: 468–474

    Article  PubMed  Google Scholar 

  15. Ertel W, Oberholzer A, Platz A, Stocker R, Trentz O (2000) Incidence and clinical pattern of the abdominal compartment syndrome after „damage-control“ laparotomy in 311 patients with severe abdominal and/or pelvic trauma. Crit Care Med 28: 1747–1753

    Article  PubMed  Google Scholar 

  16. Ertel W, Trentz O (2001) The abdominal compartment syndrome. Unfallchirurg 104: 560–568

    Article  PubMed  Google Scholar 

  17. Geeraedts LM Jr, Kamphuisen PW, Kaasjager HA, Verwiel JM, van Vugt AB, Frolke JP (2005) The role of recombinant factor VIIa in the treatment of life-threatening haemorrhage in blunt trauma. Injury 36: 495–500

    Article  PubMed  Google Scholar 

  18. Giannoudis PV, Pape HC (2004) Damage control orthopaedics in unstable pelvic ring injuries. Injury 35: 671–677

    Article  PubMed  Google Scholar 

  19. Grotz MR, Allami MK, Harwood P, Pape HC, Krettek C, Giannoudis PV (2005) Open pelvic fractures: epidemiology, current concepts of management and outcome. Injury 36: 1–13

    Article  PubMed  Google Scholar 

  20. Gustavo Parreira J, Coimbra R, Rasslan S, Oliveira A, Fregoneze M, Mercadante M (2000) The role of associated injuries on outcome of blunt trauma patients sustaining pelvic fractures. Injury 31: 677–682

    Article  PubMed  Google Scholar 

  21. Hagiwara A, Fukushima H, Murata A, Matsuda H, Shimazaki S (2005) Blunt splenic injury: usefulness of transcatheter arterial embolization in patients with a transient response to fluid resuscitation. Radiology 235: 57–64

    PubMed  Google Scholar 

  22. Hagiwara A, Murata A, Matsuda T, Matsuda H, Shimazaki S (2004) The usefulness of transcatheter arterial embolization for patients with blunt polytrauma showing transient response to fluid resuscitation. J Trauma 57: 271–277

    PubMed  Google Scholar 

  23. Harwood PJ, Giannoudis PV, van Griensven M, Krettek C, Pape HC (2005) Alterations in the systemic inflammatory response after early total care and damage control procedures for femoral shaft fracture in severely injured patients. J Trauma 58: 446–452

    PubMed  Google Scholar 

  24. Heini PF, Witt J, Ganz R (1996) The pelvic C-clamp for the emergency treatment of unstable pelvic ring injuries. A report on clinical experience of 30 cases. Injury 27 [Suppl 1A]: 38–45

    Article  Google Scholar 

  25. Holcomb JB (2005) Use of recombinant activated factor VII to treat the acquired coagulopathy of trauma. J Trauma 58: 1298–1303

    PubMed  Google Scholar 

  26. Holting T, Buhr HJ, Richter GM, Roeren T, Friedl W, Herfarth C (1992) Diagnosis and treatment of retroperitoneal hematoma in multiple trauma patients. Arch Orthop Trauma Surg 111: 323–326

    Article  PubMed  Google Scholar 

  27. Husain FA, Martin MJ, Mullenix PS, Steele SR, Elliott DC (2003) Serum lactate and base deficit as predictors of mortality and morbidity. Am J Surg 185: 485–491

    Google Scholar 

  28. Keel M, Trentz O (2005) Pathophysiology of polytrauma. Injury 36: 691–709

    Article  PubMed  Google Scholar 

  29. Khan AZ, Parry JM, Crowley WF, McAllen K, Davis AT, Bonnell BW, Hoogeboom JE (2005) Recombinant factor VIIa for the treatment of severe postoperative and traumatic hemorrhage. Am J Surg 189: 331–334

    Article  PubMed  Google Scholar 

  30. Kimbrell BJ, Velmahos GC, Chan LS, Demetriades D (2004) Angiographic embolization for pelvic fractures in older patients. Arch Surg 139: 728–732

    Google Scholar 

  31. Levi M, Peters M, Buller HR (2005) Efficacy and safety of recombinant factor VIIa for treatment of severe bleeding: a systematic review. Crit Care Med 33: 883–890

    Article  PubMed  Google Scholar 

  32. Lindner T, Bail HJ, Manegold S, Stockle U, Haas NP (2004) Shock trauma room diagnosis: initial diagnosis after blunt abdominal trauma. A review of the literature. Unfallchirurg 107: 892–902

    Article  PubMed  Google Scholar 

  33. Martinowitz U, Michaelson M (2005) Guidelines for the use of recombinant activated factor VII (rFVIIa) in uncontrolled bleeding: a report by the Israeli Multidisciplinary rFVIIa Task Force. J Thromb Haemost 3: 640-648

    Article  PubMed  Google Scholar 

  34. Melton LJ 3rd, Sampson JM, Morrey BF, Ilstrup DM (1981) Epidemiologic features of pelvic fractures. Clin Orthop Relat Res 1981: 43–47

    Google Scholar 

  35. Metz CM, Hak DJ, Goulet JA, Williams D (2004) Pelvic fracture patterns and their corresponding angiographic sources of hemorrhage. Orthop Clin North Am 35: 431–437

    PubMed  Google Scholar 

  36. Miller PR, Moore PS, Mansell E, Meredith JW, Chang MC (2003) External fixation or arteriogram in bleeding pelvic fracture: initial therapy guided by markers of arterial hemorrhage. J Trauma 54: 437–443

    PubMed  Google Scholar 

  37. Olson SA, Rhorer AS (2005) Orthopaedic trauma for the general orthopaedist: avoiding problems and pitfalls in treatment. Clin Orthop Relat Res 433: 30–37

    Article  PubMed  Google Scholar 

  38. Paar O, Sohn M, Kasperk R (1990) Strategy of the interdisciplinary early intervention in unstable pelvic injuries and concomitant urogenital lesions. Unfallchirurg 93: 353–358

    PubMed  Google Scholar 

  39. Palmer S, Fairbank AC, Bircher M (1997) Surgical complications and implications of external fixation of pelvic fractures. Injury 28: 649–653

    Article  PubMed  Google Scholar 

  40. Pape HC, Giannoudis P, Krettek C (2002) The timing of fracture treatment in polytrauma patients: relevance of damage control orthopedic surgery. Am J Surg 183: 622–629

    Article  PubMed  Google Scholar 

  41. Pape HC, Grimme K, Van Griensven M et al. (2003) Impact of intramedullary instrumentation versus damage control for femoral fractures on immunoinflammatory parameters: prospective randomized analysis by the EPOFF Study Group. J Trauma 55: 7–13

    PubMed  Google Scholar 

  42. Pape HC, Hildebrand F, Krettek C (2004) Decision making and and priorities for surgical treatment during and after shock trauma room treatment. Unfallchirurg 107: 927–936

    Article  PubMed  Google Scholar 

  43. Pape HC, Hildebrand F, Pertschy S et al. (2002) Changes in the management of femoral shaft fractures in polytrauma patients: from early total care to damage control orthopedic surgery. J Trauma 53: 452–461

    PubMed  Google Scholar 

  44. Pape HC, Krettek C (2003) Damage control orthopaedic surgery. Unfallchirurg 106: 85–86

    Article  PubMed  Google Scholar 

  45. Pape HC, Krettek C (2003) Management of fractures in the severely injured — influence of the principle of „damage control orthopaedic surgery“. Unfallchirurg 106: 87–96

    Article  PubMed  Google Scholar 

  46. Pehle B, Nast-Kolb D, Oberbeck R, Waydhas C, Ruchholtz S (2003) Significance of physical examination and radiography of the pelvis during treatment in the shock emergency room. Unfallchirurg 106: 642–648

    Article  PubMed  Google Scholar 

  47. Perez JV, Hughes TM, Bowers K (1998) Angiographic embolisation in pelvic fracture. Injury 29: 187–191

    Article  PubMed  Google Scholar 

  48. Pohlemann T, Bosch U, Gansslen A, Tscherne H (1994) The Hannover experience in management of pelvic fractures. Clin Orthop Relat Res 305: 69–80

    PubMed  Google Scholar 

  49. Pohlemann T, Braune C, Gansslen A, Hufner T, Partenheimer A (2004) Pelvic emergency clamps: anatomic landmarks for a safe primary application. J Orthop Trauma 18: 102–105

    Article  PubMed  Google Scholar 

  50. Pohlemann T, Culemann U, Gansslen A, Tscherne H (1996) Severe pelvic injury with pelvic mass hemorrhage: determining severity of hemorrhage and clinical experience with emergency stabilization. Unfallchirurg 99: 734–743

    Article  PubMed  Google Scholar 

  51. Pohlemann T, Tscherne H, Baumgartel F et al. (1996) Pelvic fractures: epidemiology, therapy and long-term outcome. Overview of the multicenter study of the Pelvis Study Group. Unfallchirurg 99: 160–167

    Article  PubMed  Google Scholar 

  52. Poole GV, Ward EF, Muakkassa FF, Hsu HS, Griswold JA, Rhodes RS (1991) Pelvic fracture from major blunt trauma. Outcome is determined by associated injuries. Ann Surg 213: 532–539

    PubMed  Google Scholar 

  53. Rittmeister M, Lindsey RW, Kohl HW 3rd (2001) Pelvic fracture among polytrauma decedents. Trauma-based mortality with pelvic fracture--a case series of 74 patients. Arch Orthop Trauma Surg 121: 43–49

    Google Scholar 

  54. Rothenberger DA, Fischer RP, Strate RG, Velasco R, Perry JF Jr (1978) The mortality associated with pelvic fractures. Surgery 84: 356–361

    PubMed  Google Scholar 

  55. Rotondo MF, Schwab CW, McGonigal MD, Phillips GR, 3rd, Fruchterman TM, Kauder DR, Latenser BA, Angood PA (1993) „Damage control“: an approach for improved survival in exsanguinating penetrating abdominal injury. J Trauma 35: 375–382

    PubMed  Google Scholar 

  56. Rotondo MF, Zonies DH (1997) The damage control sequence and underlying logic. Surg Clin North Am 77: 761–777

    Article  PubMed  Google Scholar 

  57. Ruchholtz S, Waydhas C, Lewan U, Pehle B, Taeger G, Kuhne C, Nast-Kolb D (2004) Free abdominal fluid on ultrasound in unstable pelvic ring fracture: is laparotomy always necessary? J Trauma 57: 278–285

    PubMed  Google Scholar 

  58. Ruchholtz S, Waydhas C, Schroeder T, Piepenbrink K, Kuhl H, Nast-Kolb D (2002) The value of computed tomography in the early treatment of seriously injured patients. Chirurg 73: 1005–1012

    Article  PubMed  Google Scholar 

  59. Seekamp A, Burkhardt M, Pohlemann T (2004) Shock trauma room management of pelvic injuries. A systematic review of the literature. Unfallchirurg 107: 903–910

    Article  PubMed  Google Scholar 

  60. Shah NS, Kelly E, Billiar TR, Marshall HM, Harbrecht BG, Udekwu AO, Peitzman AB (1998) Utility of clinical parameters of tissue oxygenation in a quantitative model of irreversible hemorrhagic shock. Shock 10: 343–346

    Google Scholar 

  61. Shapiro MB, Jenkins DH, Schwab CW, Rotondo MF (2000) Damage control: collective review. J Trauma 49: 969–978

    PubMed  Google Scholar 

  62. Shoemaker WC, Peitzman AB, Bellamy R et al. (1996) Resuscitation from severe hemorrhage. Crit Care Med 24: 12–23

    Article  Google Scholar 

  63. Siegmeth A, Mullner T, Kukla C, Vecsei V (2000) Associated injuries in severe pelvic trauma. Unfallchirurg 103: 572–581

    Article  PubMed  Google Scholar 

  64. Tiemann AH, Schmidt C, Gonschorek O, Josten C (2004) Use of the „c-clamp“ in the emergency treatment of unstable pelvic fractures. Zentralbl Chir 129: 245–251

    Article  PubMed  Google Scholar 

  65. Tile M (1996) Acute pelvic fractures: I. Causation and classification. J Am Acad Orthop Surg 4: 143–151

    Google Scholar 

  66. Tile M, Helfet DL, Kellam JF (2003) Fractures of the pelvis and acetabulum. Lippincott, Williams & Wilkins, Philadelphia, pp 61–79

  67. Tscherne H, Pohlemann T (1998) AO-Klassifikation. In: Tscherne H, Pohlemann T (Hrsg) Tscherne Unfallchirurgie — Becken und Acetabulum. Springer, Berlin Heidelberg New York, S. 52–59

  68. Weinberg AM, Reilmann H (1992) The pelvic professional section of the German Society of accident surgery and the German section of AO-International. Orthopade 21: 449–452

    PubMed  Google Scholar 

  69. Witschger P, Heini P, Ganz R (1992) Pelvic clamps for controlling shock in posterior pelvic ring injuries. Application, biomechanical aspects and initial clinical results. Orthopade 21: 393–399

    PubMed  Google Scholar 

  70. Ziran BH, Chamberlin E, Shuler FD, Shah M (2005) Delays and difficulties in the diagnosis of lower urologic injuries in the context of pelvic fractures. J Trauma 58: 533–537

    PubMed  Google Scholar 

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  1. Zentrum für spezielle Chirurgie des Bewegungsapparates, Klinik für Unfall- und Wiederherstellungschirurgie, Charité — Universitätsmedizin Berlin, Campus Benjamin Franklin, Berlin

    T. John & W. Ertel

  2. Zentrum für spezielle Chirurgie des Bewegungsapparates, Klinik für Unfall- und Wiederherstellungschirurgie, Charité — Universitätsmedizin Berlin, Campus Benjamin Franklin, Hindenburgdamm 30, 12200, Berlin

    T. John

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John, T., Ertel, W. Die Beckenringzerreißung beim polytraumatisierten Patienten. Orthopäde 34, 917–930 (2005). https://doi.org/10.1007/s00132-005-0860-3

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