[Influence of the pelvic trauma registry of the DGU on treatment of pelvic ring fractures]. / Einfluss des Beckenregisters der DGU auf die Versorgung von Beckenringfrakturen.

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.

[Complex pelvic traumas : data linkage of the German Pelvic Injury Register and the TraumaRegister DGU®]. / Das komplexe Beckentrauma : Matching des Beckenregisters DGU mit dem TraumaRegister DGU®.

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.

[Current treatment of pelvic ring fractures]. / Aktuelle Behandlung der Beckenringfraktur.

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.

[Current treatment of pelvic ring fractures]. / Aktuelle Behandlung der Beckenringfraktur.

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.

[Acetabular fractures in the elderly. Outcome of open reduction and internal fixation]. / Osteosynthese bei Acetabulumfrakturen im Alter. Ist eine Rekonstruktion sinnvoll?

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'Aubigné 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'Aubigné 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.

[Concept for treatment of pelvic ring injuries in elderly patients. A challenge]. / Versorgungskonzept der Beckenringverletzung des alten Patienten. Eine Herausforderung.

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. This is followed by imaging with X-ray and CT scanning with 3D reconstruction if necessary. If there are concomitant injuries additional diagnostics are essential (e.g. sonography, MRI, retrograde ureterography, cystography and excretion urogram). The standard AO/ATO classification (Arbeitsgemeinschaft für Osteosynthesefragen/Orthopedic Trauma Association) has been well proven and does not depend on the age of the patient. Three different fracture types are differentiated, types A, B and C. This classification in combination with the description of the affected anatomical region (e.g. transsymphysis, transpubic, etc.) is sufficient in the daily clinical practice to decide on the necessary treatment. Often there are diagnostic difficulties in elderly patients (so-called differentiation of the A-B problem). In these patients a type A fracture is initially diagnosed and treated conservatively but due to persistent pain the imaging is repeated and an additional (insufficiency) fracture is found. With this new information the therapeutic regime has to be changed. The reconstruction of the pelvic ring is of major importance especially for elderly patients. This reduces the pain and the primary objective, an earliest possible rehabilitation without prolonged immobilization, can be achieved. In elderly patients external fixation with supra-acetabular screw positioning is an effective procedure and secondary insufficiency-instability (mostly dorsal) can be avoided. Whereas type A fractures can almost exclusively be treated non-surgically, types B and C fractures usually need surgery. 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.

[Complex pelvic trauma in elderly patients]. / Das komplexe Beckentrauma des älteren Patienten.

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).

Changes in epidemiology and treatment of pelvic ring fractures in Germany: an analysis on data of German Pelvic Multicenter Study Groups I and III (DGU/AO).

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 algorithms 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.

Different stabilisation techniques for typical acetabular fractures in the elderly--a biomechanical assessment.

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.

Rapamycin affects early fracture healing in mice.

BACKGROUND AND PURPOSE: The immunosuppressive drug rapamycin (RAPA) prevents rejection in organ transplantation by inhibiting interleukin-2-stimulated T-cell division. Rapamycin has also been suggested to possess strong anti-angiogenic activities linked to a decrease in production of vascular endothelial growth factor (VEGF). Angiogenesis and VEGF are thought to play a crucial role in fracture healing and as osteoporotic and traumatic fractures are common complications in immunosuppressed, organ transplantation patients, we conducted this study to analyze the effect of rapamycin treatment on bone repair. EXPERIMENTAL APPROACH: We investigated the effect of rapamycin treatment on bone repair in a murine closed femur fracture model using radiological, histomorphometric, immunohistochemical, biomechanical and protein biochemical analyses. KEY RESULTS: X-ray analyses demonstrated that rapamycin treatment inhibits callus formation after two weeks of fracture healing. The radiologically observed lack of callus formation was confirmed by histomorphometric analyses, which revealed a significantly diminished callus size and a reduced amount of bone formation when compared with vehicle-treated controls. Biomechanical testing further demonstrated that rapamycin significantly reduces torsional stiffness of the callus. Interestingly, this effect was associated with decreased vessel formation; a diminished proliferation of osteoblasts, endothelial cells and periosteal cells; and a reduced VEGF expression in hypertrophic chondrocytes. After five weeks treatment, however, the negative impact of rapamycin on fracture healing was overcome. CONCLUSIONS AND IMPLICATIONS: Thus, rapamycin initially delays fracture healing, most probably by inhibiting cell proliferation and neovascularization in the callus. These undesirable effects should be considered when rapamycin is administered to patients sustaining bone fractures.

A new technique for internal fixation of femoral fractures in mice: impact of stability on fracture healing.

Mouse models are of increasing interest to study the molecular aspects of fracture healing. Because biomechanical factors greatly influence the healing process, stable fixation of the fracture is of interest also in mouse models. Unlike in large animals, however, there is a lack of mouse models which provide stable osteosynthesis. The purpose of this study was therefore to develop a technique for a more stable fixation of femoral fractures in mice and to analyze the impact of stability on the process of fracture healing. The new technique introduced herein includes an intramedullary pin and an extramedullary metallic clip. Ex vivo biomechanical analysis revealed a significantly higher implant stiffness of our pin-clip technique when compared with previously described intramedullary fixation techniques. In vivo, we studied the course of healing after the more stable fixation with our pin-clip technique and compared the results with that observed after unstable fixation with the pin-clip technique after cutting the clip. After 2 and 5 weeks of fracture healing radiological analysis demonstrated that the more stable fixation with the pin-clip technique results in a significantly higher union rate compared to the unstable fixation. Torsional stiffness at 5 weeks was almost 3-fold of that measured after unstable fixation. Histomorphological analysis further showed that fractures stabilized with the pin-clip technique healed with a smaller periosteal callus area, an increased fraction of bone and a reduced amount of fibrous tissue. Of interest, the pin-clip fixation showed reliable union after 5 weeks, whereas the unstable pin fixation did not regularly achieve adequate fracture healing. In conclusion, we introduce a novel, easily applicable internal osteosynthesis technique in mice, which provides rotational stability after femoral fracture fixation. We further show that a more stable osteosynthesis significantly improves the process of fracture healing also in mice.

[Visualization of reduction. New view of a dynamic procedure]. / Visualisierung von Repositionspfaden. Neuartige Betrachtungsweise von Repositionsvorgängen.

BACKGROUND: Evaluation of a reduction is currently a static procedure. The purpose of this study was to evaluate a model for analyzing the whole dynamic component of the reduction path up to the final result: the optimal reduction. The entire reduction procedure should be able to be retrospectively analyzed, both qualitatively and quantitatively. METHODS: Two examiners of different experience levels had to solve multiple predefined tasks, which were noted with the assistance of a motion tracking system in all space axes. The noted paths of reduction were then analyzed with the MATLAB program and some additional quantitative and qualitative tools. RESULTS: Both examiners had to accomplish a typical number of characteristic movement samples in typical number, in order to arrive at the same final result. After the temporal component was eliminated, the reduction process showed typical turning points that represented essential conditions for achieving an optimal result. CONCLUSION: Using the presented model the paths in a reduction process can be achieved as data in a simple manner. These data are supplied in a second work procedure of an automated evaluation. Thus, multiple possibilities result for retrospective analysis of the data regarding the dynamic process of a reduction.

[Epiphysiolysis of the dens axis in the small child]. / Die traumatische Epiphysiolyse des Dens axis beim Kleinkind.

Epiphysiolysis of the dens axis at the infant age is a rare injury, which must be surely clarified at car accidents with frontal application of force at medium high speed. We report of a small patient sitting in a child seat, who suffered a epiphysiolysis of the dens axis, which was initially not diagnosed, due to a abrupt deceleration in the context of a car accident. The epiphysiolysis of the dens axis could be secured with the aid of conventional radiography, MRT and CT. The delayed conservative treatment due to the anamnesis was then complicationless.

[Percutaneous sacroiliac lag screw fixation of the posterior pelvic ring. Increasing safety by standardization of visualization and insertion technique]. / Die perkutane transiliosakrale Zugschraubenosteosynthese des hinteren Beckenrings. Erhöhte Sicherheit durch Standardisierung von Visualisierung und Technik.

BACKGROUND: In recent years, the closed reduction and percutaneous fixation of posterior pelvic ring fractures by sacroiliac screws has become a well established treatment option for stabilization of posterior pelvic ring disruptions. Stable percutaneous pelvic ring fixation also implies a very low complication rate, e.g., in operative blood loss, wound healing, and operative time. To avoid malpositioning of the screws, sufficient reduction and radiologic visualization are essential. The surgical technique has been described in several studies; however, great importance is attached to the personal experience of the surgeon. Therefore, this study was conducted to establish a standard procedure that allows different surgeons a safe positioning of sacroiliac screws. RESULTS: A total of 41 injuries of the posterior pelvic ring were stabilized with 73 sacroiliac lag screws inserted by 7 different surgeons using a standardized technique. In all cases adequate reduction of the fracture and radiologic visualization were achieved. No wound infections, no relevant bleedings, and no spiral fractures of screws were observed. In two cases malpositioning led to revision of the screws. Of interest, one case of S1 paresthesia resulting from a malpositioned screw could be revised. In contrast, two cases of screw loosening and one case of screw bending did not require further intervention. CONCLUSION: We conclude that safe positioning of the sacroiliac screws was accomplished by all surgeons given a standardized technique. For safe insertion preparation of the patients, accurate visualization of the fracture zone, and potential closed reduction is always required.

[Biomechanical comparison of different stabilisation devices for transforaminal sacral fracture. Is an interlocking device advantageous?]. / Vergleichende biomechanische Untersuchung zur internen Stabilisierung der transforaminalen Sakrumfraktur. Ist eine winkelstabile Plattenosteosynthese vorteilhaft?

BACKGROUND: Reliable osteosynthesis for fractures in the different regions of the human pelvis are described in the literature while there is no common and satisfying treatment for unstable sacral fractures. Because of the posterior pelvic rings special anatomic conditions a local plate osteosynthesis seems to be advantageous. In many fields of modern fracture treatment locking implants show superior results. The prototype of a local locking plate osteosynthesis was compared to a common local plate and two sacroiliac screws. METHODS: The implants were tested using six plastic models of the pelvis and three embalmed human specimens. A Tile C1 fracture was created by disruption of the pubic symphysis and a transforaminal osteotomy. The specimens were exposed to axial loading in an upright single-leg stance with a maximum of 800 N for the plastic models and 200 N for the human specimens. An ultrasonic-based measuring system recorded translations (X, Y, Z) and rotations (alpha, beta, gamma). Parameters such as pattern of motion, translation/rotation, load to failure and remaining dislocation were evaluated. RESULTS: Concerning most of the evaluated parameters the local plate osteosynthesis was inferior compared with two sacroiliac screws. There were no significant differences between the locking implant and the local plate osteosynthesis. Compared with the two sacroiliac screws the locking implant shows biomechanically equal results but allows greater anterior rotation and remaining dislocation. Because of the lower bone quality, the results from the anatomic specimen tested were not utilisable. CONCLUSIONS: The locking implant is biomechanically an alternative compared with two sacroiliac screws. Problems occurred due to the preset direction of the locking head screws.

Development of a locking femur nail for mice.

We herein report on a novel locking intramedullary nail system in a murine closed femur fracture model. The nail system consists of a modified 24-gauge injection needle and a 0.1-mm-diameter tungsten guide wire. Rotation stability was accomplished by flattening the proximal and distal end of the needle. Torsional mechanical testing of the implants in osteotomized cadaveric femora revealed a superiority of the locking nail (3.9+/-1.0 degrees rotation at a torque of 0.9 Nmm, n=10) compared to the unmodified injection needle (conventional nail; 52.4+/-3.2 degrees, n=10, p<0.05). None of the implants, however, achieved the rotation stability of unfractured femora (0.3+/-0.5 degrees, n=10). In a second step, we tested the feasibility of the in vivo application of the locking nail to stabilize a closed femoral midshaft fracture in C57BL/6 mice. Of interest, none of the 10 animals showed a dislocation of the locking nail over a 5-week period, while 3 of 4 animals with conventional nail fracture stabilization showed a significant pin dislocation within the first 3 days (p<0.05). Mechanical testing after 5-weeks stabilization with the locking nail revealed an appropriate bone healing with a torque at failure of 71.6+/-3.4% and a peak rotation before failure of 68.4+/-5.3% relative to the unfractured contralateral femur. With the advantage that closed fractures can be fixed with rotation stability, the herein introduced model may represent an ideal tool to study bone healing in transgenic and knockout mice.

[Blunt pelvic injury]. / Stumpfe Beckenverletzung.

Life-threatening complex pelvic fractures are commonly associated with vast peripelvine soft-tissue injuries and hemorrhage. Correct assessment and classification of the existing pelvic trauma and additional severe injuries present is required for accurate diagnosis and effective therapy. Treatment of the usually multiply injured patient is time-sensitive. The circulatory situation is the benchmark for diagnostic and therapeutic actions. Emergency stabilization of an initially unstable pelvic ring should be done first, followed by an extraperitoneal tamponade, if needed to control bleeding. The positive results of these actions can be measured by hemodynamic parameters. Delayed definitive internal stabilization of the anterior and/or posterior pelvic ring is then performed according to the fracture classification.

[Misinterpretation of anterior pelvic ring fractures in the elderly]. / Fehleinschätzung bei vorderer Beckenringfraktur im höheren Lebensalter.

Clinical outcome following pelvic ring fractures of AO/OTA type-A in the elderly is often unsatisfying because the posterior pelvic ring fracture is underdiagnosed and patients with type B fractures were conservatively treated like patients with type A fractures. This so-called "A-B" problem was systematically analyzed in our patients with pelvic ring fractures. 183 patients were treated with pelvic ring fractures. Primarily, the injuries were classified as follows: 81 type A, 38 type B, and 64 type C. The diagnosis was changed from type A to type B injury in seven patients. Parameters of investigation included fracture type, duration of symptoms, treatment, and outcome score according to the German Multicenter Study Group Pelvis. Persistent pain in the sacral area over an average of 2 (1-6) weeks was found in all patients. The CT scan revealed in all patients a transalar sacral impression fracture in the sense of an internal rotationally unstable injury of type AO/OTA B 2.1. The treatment consisted in a supra-acetabular external fixator for an average of 3 weeks. After 4 weeks the mean pelvis outcome score was 9 (7-10) points. In cases of persistent pain for more than 2 weeks after transpubic pelvic ring fractures in the elderly further investigation by CT scan should be recommended to exclude a concomitant sacral fracture, which then could be safely treated by a supra-acetabular external fixator.