Der Unfallchirurg
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Injuries of the lower urinary tract occur in patients with multiple injuries and trauma to the lower abdominal and pelvic region. Injuries of the male urethra including complete ruptures occur in 10% of pelvic fractures in males, while they are a rarity in females. Ruptures of the urinary bladder are either intra- or extraperitoneal. ⋯ In male patients with pelvic fractures any attempt of urethral catheterization which can otherwise make an urethral injury worse should be withheld until adequate urological examinations have led to the diagnosis or exclusion of urethral injury. The definitive surgical repair of a disruption of the male urethra should be undertaken with an interval of weeks to months. Long term sequelae of male urethral injury can be impotence and chronic stricture disease.
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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. ⋯ 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).
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The physical examination of the knee in cases of suspected meniscal tears serves to increase the probability of a correct diagnosis. Although there is a large variety of functional tests, the quality of each diagnostic test is controversially discussed. ⋯ Meniscal injury can be detected by several functional tests. Using the Thessaly test can improve the physical examination by means of probability of the correct diagnosis, but the results are based on a single study. In patients with ambiguous findings in the physical examination or with suspected combined injury, further diagnostic procedures such as magnetic resonance imaging are necessary to confirm the diagnosis. In clinically certain cases the use of additional diagnostic imaging procedures should be avoided as other authors have shown that with few exceptions this has no influence on the therapy.
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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. ⋯ 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.
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Fractures of the pelvis are of increasing interest, especially in older patients due to the often concomitant osteoporosis. The low bone quality can be a problem in several fixation situations. In this review the present and relevant literature on biomechanical data of unstable pelvic ring injuries and all biomechanical data dealing with osteosynthesis for acetabular fractures are discussed.