Gen er ally, pel vic frac tures are se vere in ju ries that can

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1 /STRU^NI RAD UDK : DOI: /ACI M Urinary tract injury associated with pelvic fractures... Saša Milenkovi} 1, Mi lan Mitkovi} 2, Dragoslav Baši} 3, Stojanka Arsi} 4, Jovan Had`i Djoki} 5, Milorad Mitkovi} 1 1 Uni ver sity of Ni{, Med i cal fac ulty, Or tho pae dic&traumatology Clinic, Ni{, Serbia 2 Or tho pae dic&traumatology Clinic, Ni{, Serbia 3 Uni ver sity of Ni{, Med i cal fac ulty, Urol ogy Clinic, Ni{, Serbia 4 Uni ver sity of Ni{, Med i cal fac ulty, Anat omy In sti tute, Serbia 5 Ser bian Acad emy of Sci ence and Arts, Bel grade, Serbia IN TRO DUC TION: Pel vic trauma as so ci ated with uri nary tract in jury is a se vere trauma, mostly caused by traf fic ac ci dents and falls from heights. These in ju ries re quire ur gent treat ment and close teamwork between urologic and orthopaedic sur - geons. MA TE RIAL AND METH ODS: In this ret ro spec - tive study there were an a lyzed pa tients with pel - vic trauma and extraperitoneal in jury of uri nary tract, treated sur gi cally at Clinic for Ortopaedic Surgery and Traumatology and Urol ogy Clinic in Clin i cal Center Nis. Surgical intervention in these patients had been re al ized as the syn chro nized work of both or tho - pae dic and uro logic sur geons. The pel vis was treated by ex ter nal and in ter nal fix a tion. Mitkovic type ex ter - nal fixator was used for pel vic ex ter nal fix a tion. Plat - ing was used for pel vic in ter nal fix a tion. Pel vic frac - tures were clas si fied us ing Tile s clas si fi ca tion sys tem. The fi nal func tional re sults had been scored us ing Majeed score sys tem. RE SULTS: There were 42 pa tients with the in jury of pel vic ring, treated at Clinic for Ortopaedic Sur gery and Traumatology and at Urol ogy Clinic, Clin i cal Cen ter Nis, in the pe riod of to , 30 males and 12 fe males, with av er age age of (19-84) years old. In 80% of cases pel vic frac tures were caused by high en ergy trauma in traf fic ac ci - dents. According to Tile s classification, 9 patients (21,42%) had pel vic frac ture type A, 23 pa tients (54,46%) had pel vic frac ture type B and 10 pa tients (23,80%) had pel vic frac ture type C. Urinary tract in - jury was di ag nosed in 9 pa tients (21,42%): 5 pa tients (11,9%) with blad der in jury, 3 patients (7,14%) with pos te rior ure thra in jury and 1 patient (2,38%) with both blad der and pos te rior ure thra in jury. CON CLU SION: Ur gent re pair of extraperitoneal uri - nary tract in jury by uro logic sur geons and syn chro - nized pelvic reduction and fixation using external or in ter nal fix a tion by ortopaedic sur geon, in the same rezime sur gi cal pro ce dure, is the stan dard method for treat - ment of this se vere injury. Key words: Uri nary tract, In jury, Pel vic Frac tures INTRODUCTION Gen er ally, pel vic frac tures are se vere in ju ries that can be sep a rated or as so ci ated with in ju ries of other or - gans and or gan sys tems. Pel vic trauma is of ten pres ent in polytrauma. Main causes of these in ju ries are high en - ergy trauma in traf fic ac ci dents or falls from height. Pel - vic frac tured pa tients can be haemodinamically sta ble or un sta ble. Pel vic frac tures can be sta ble or un sta ble. Biomechanical in sta bil ity may pro voke hemodynamical in sta bil ity in the acute phase be cause dis rupted pel vic ring leads to dam age to the pel vic or gans and many pel - vic ves sels 1. The close an a tom i cal re la tion ship be tween the skel e tal and con nec tive sys tems of the pel vis, neu ro - log i cal, vas cu lar struc tures and pel vic or gans are pre dis - pos ing fac tors for struc tural and func tional dam age of uro gen i tal sys tem 2. The blad der and ure thra are lo cated in close prox im ity to the pel vic bones and these struc tures are sus cep ti ble to in ju ries when the pel vic ring is dis - rupted. Uri nary tract in jury as so ci ated with pel vic trauma are well known and de scribed in lit er a ture 3,4. Ac cord ing to lit er a ture datas, 16% of pel vic frac tures are as so ci ated with uri nary tract in ju ries 4. More over, among 25% of pa - tients with pel vic ring trauma have any type of uri nary tract le sions that were ei ther doc u mented ra dio log i cally, or were found dur ing sur gery 5. In jury to the blad der ranges from con tu sion, which man i fests as mi cro scopic hematuria, to blad der rup ture which usu ally pres ents with gross hematuria 6,7. OB JEC TIVE Pel vic ring frac tures are se vere in ju ries and it is of ten as so ci ated with uri nary tract in jury. These as so ci ated in - ju ries re quire close team work be tween uro logic and or - tho pae dic sur geons. The aim of this study is to pres ent

2 10 S. Milenkovi} et al. ACI Vol. LXI TABLE 1 TILE'S CLASSIFICATION OF PELVIC DISRUPTION A1 A2 B1 B2 B3 C1 Type A - Sta ble Frac tures of the pel vis not in volv ing the ring Sta ble, min i mally dis placed frac tures of the ring Type B- Rotationally un sta ble, ver ti cally sta ble Open book Lat eral com pres sion: ipsilateral Lat eral com pres sion: contralateral (bucket-han - dle) Type C - Rotationally and ver ti cally un sta ble Rotationally and ver ti cally un sta ble A9(21,42%) B23(54,46%) C10(23,8%) FIGURE 1. PEL VIC FRAC TURES AC CORD ING TO TILE S CLAS SI - FICATION C2 C3 Bi lat eral As so ci ated with an acetabular frac ture 9(21,42%) our re sults in treat ment of pa tients with both pel vic and uri nary tract in jury. MA TE RIAL& METH ODS In this ret ro spec tive study there were an a lyzed pa tients with both pel vic trauma and extraperitoneal uri nary tract in jury, treated sur gi cally at Clinic for Ortopaedic Sur gery and Traumatology and Urol ogy Clinic in Clin i cal Cen ter Nis. These pa tients were treated sur gi cally in the same sur gi cal pro ce dure, by syn chro nized team work of or tho - pe dic and urol ogy sur geons. In one case there was the need for ad di tional or tho pae dic sur gi cal in ter ven tion re - gard ing to de fin i tive sta bi li za tion of un sta ble pel vic ring frac ture. As fix a tion ma te rial were used Mitkovic ex ter - nal fix a tion de vice (Ortokon, Ser bia) and plates (Synthes, USA). Re gard ing to pel vic trauma, X-rays (AP, In let, Out let) and CT were used as di ag nos tic pro ce dures. Re - gard ing to uro logic trauma, catheterization, con trast urethrography, cystography and CT con trast cystography were used as di ag nos tic pro ce dures. Pel vic frac tures were clas si fied us ing Tile s clas si fi ca tion sys tem (Ta ble 1) 8. The fi nal func tional re sults had been scored us ing Majeed scor ing sys tem 9. RE SULTS Ac cord ing to Tile s clas si fi ca tion, 9 pa tients (21,42%) had pel vic frac ture type A, 23 pa tients (54,46%) had pel - vic frac ture type B and 10 pa tients (23,80%) had pel vic frac ture type C (Fig ure 1). Uri nary tract in jury was di ag nosed in 9 pa tients (21,42%): 5 pa tients (11,9%) with blad der in jury, 3 pa - tients (7,14%) with pos te rior ure thra in jury and 1 pa tient (2,38%) with both blad der and pos te rior ure thra in jury (Fig ure 2,3). In the group of 9 pa tients (21,42%) with uri - nary tract in jury 7 pa tients (16,66%) had pel vic frac ture FIG URE 2. URINARY TRACT INJURY ASSOCIATED WITH PELVIC FRACTURES. Bladder 5-11,9% Urethra 3-7,14% Both 1-2,38% FIGURE 3. DIS TRI BU TION OF THE URI NARY TRACT IN JURY ASSOCIATED WITH PELVIC FRACTURES. tttype B (Fig ure 4,5) and 2 pa tients (4,76%) had pel vic frac ture type C. All pa tients with both blad der and pos te - rior ure thra in jury were treated sur gi cally, to gether with re duc tion and fix a tion of the pel vic ring in the same sur - gi cal pro ce dure. As the pro ce dure of Dam age Con trol Or tho pae dic (DCO) 10, in 1 case there was per formed pri - mary blad der re pair and ex ter nal fix a tion of type C frac - tured un sta ble pel vis ring. Af ter the sta bi li za tion of vi tal pa ram e ters and gen eral health sta tus, there was per - formed sec ond ary sur gi cal pro ce dure re moval of ex ter - nal fixator and de fin i tive sta bi li za tion of an te rior and

$Br. 1 Uri nary tract in jury as so ci ated with pel vic frac tures 11 FIG URE 4. MSCT SCAN OF PU BIC SYMPHYSIS DIS RUP TION.$ THE PEL VIS WAS FIXED US ING MITKOVIC TYPE EX TER NAL FIXATOR (B, C); STA BLE FIX A TION OF PEL VIC RING EN ABLES EARLY PA TIENT S AC TI VA TION (D, E).

THE PEL VIS WAS FIXED US ING MITKOVIC TYPE EX TER NAL FIXATOR (B, C); STA BLE FIX A TION OF PEL VIC RING EN ABLES EARLY PA TIENT S AC TI VA TION (D, E).

Re gard less to these func tional re sults there was the need for fur ther uro log i - cal treat ment of uri nary in con ti nence in 1 case, 1 pa tient had erec tile dys func tion and 1 pa tient had

$The treat ment of these in ju ries is of ten sep a rate and spe cific, es pe cially in un sta ble pel vic frac tures as so ci ated with uri nary tract in - jury.$ Re gard ing to or tho pae dic sur geons ob ject, it is man da tory to ob tain pel vic ring sta bi li za tion, nec es - sary to re duce pos si ble con se quences such as chronic back pain, im pos si

Re gard ing to or tho pae dic sur geons ob ject, it is man da tory to ob tain pel vic ring sta bi li za tion, nec es - sary to re duce pos si ble con se quences such as chronic back pain, im pos si

3 Br. 1 Uri nary tract in jury as so ci ated with pel vic frac tures 11 FIG URE 4. MSCT SCAN OF PU BIC SYMPHYSIS DIS RUP TION. PEL VIC FRAC TURE TYPE B (OPEN BOOK) (A); THE BLAD DER AND URE THRA RUP TURES HAD BEEN DI AG NOSED INTRAOPERATIVELY. BLAD DER AND URE THRAL RE PAIR HAD BEEN DONE. THE PEL VIS WAS FIXED US ING MITKOVIC TYPE EX TER NAL FIXATOR (B, C); STA BLE FIX A TION OF PEL VIC RING EN ABLES EARLY PA TIENT S AC TI VA TION (D, E). pos te rior pel vic ring com plex by in ter nal fix a tion (Fig ure 6). Ac cord ing to Majeed score fi nal func tional re sult was ex cel lent in 5 and good in 4 cases. Re gard less to these func tional re sults there was the need for fur ther uro log i - cal treat ment of uri nary in con ti nence in 1 case, 1 pa tient had erec tile dys func tion and 1 pa tient had dyspareunia af ter blad der re pair and symphyseal plate fix a tion. DIS CUS SION Pel vic trauma as so ci ated with uri nary tract in jury is pre sented as very se vere in jury sta tus. The treat ment of these in ju ries is of ten sep a rate and spe cific, es pe cially in un sta ble pel vic frac tures as so ci ated with uri nary tract in - jury. Health con se quences and per ma nent dis abil ity are pos si ble to oc cur re gard less to the ad e quate treat ment of these in ju ries. Re gard ing to or tho pae dic sur geons ob ject, it is man da tory to ob tain pel vic ring sta bi li za tion, nec es - sary to re duce pos si ble con se quences such as chronic back pain, im pos si bil ity of stand ing and sit ting for long time and unequality of lower limbs 1. Uro logic in ter ven - tion is nec es sary to ob tain nor mal uri nary tract func tion. Se ri ous lat ter sex ual dys func tion is found in sig nif i cant num ber of pa tients 11. All these con di tions can lead to per - ma nent dis abil ity and very se vere and con tin u ous psy chi - cal prob lems. Pel vic frac tures in duced by high en ergy trauma can be sta ble, par tial un sta ble or un sta ble 8. Pel vic frac tures can be pres ent as sep a rated in jury, in polytrauma or in jury as so ci ated with other or gans and or gan sys tems in jury. Uri nary tract in jury oc cur rence is pro por - tional to se ver ity of pel vic ring frac ture 12. Blad der and ure thra in jury is more pos si ble to oc cur to gether with pu - bic symphysis in jury or pu bic bone frac tures, be cause of their closed an a tom i cal po si tion. Among pa tients with rup ture of the symphysis al most 42% had have uri nary tract in jury 13. Most of as so ci ated in ju ries oc cur with a full blad der. In jury of the uro gen i tal or gans dur ing pel vic trauma has an im por tant neg a tive prog nos tic value in terms of mor bid ity and qual ity of life. Early di ag no sis, early sur gi cal in ter ven tion, or tho pae dic and uro logic sur - geons team work are con sid ered as the stan dard treat ment pro to col for these in ju ries 14. Dyagnosis of pel vic ring trauma re quires phys i cal ex am i na tion, X-rays (AP, In let, Oulet) and of ten CT. Di ag no sis of uri nary tract trauma re quire phys i cal ex am i na tion and ure thral catheterisation. The ma jor sign of uri nary in jury is mac ro scopic hematuria which is pres ent in 82-95% of pa tients, while 5-15% of pa tients may have only mi cro scopic hematuria 15. Haematuria pres ence re quires ad e quate di ag nos tic

12 S. Milenkovi} et al. ACI Vol. LXI A B C FIG URE 5.

IN TER NAL FIX A TION (PLAT ING) OF PU BIC SYPHYSIS. BLAD DER RE PAIR HAD BEEN PER FORM IN THE SAME SUR GI CAL PRO CE DURE (C). pro ce dures.

Be cause most of cases re quire CT scans to eval u ate pel vic or intraabdominal in jury, CT cystogram might be rec om mended in pa tients with sus pected trauma of the uri nary tract 16.

4 12 S. Milenkovi} et al. ACI Vol. LXI A B C FIG URE 5. PU BIC SYMPHYSIS DIS RUP TION CAUSED BY HIGH EN ERGY TRAUMA IN CAR AC CI DENT IN - JURY (TYPE B- OPEN BOOK) (A); BLAD DER RUP TURE WITH THE CON TRAST EXTRAVASATION (B); X-RAY AF TER RE DUC TION AND IN TER NAL FIX A TION (PLAT ING) OF PU BIC SYPHYSIS. BLAD DER RE PAIR HAD BEEN PER FORM IN THE SAME SUR GI CAL PRO CE DURE (C). pro ce dures. For early di ag no sis the ret ro grade cystography should be per formed af ter ure thral or suprapubic catheterization 12. Be cause most of cases re quire CT scans to eval u ate pel vic or intraabdominal in jury, CT cystogram might be rec om mended in pa tients with sus pected trauma of the uri nary tract 16. When ure thral in jury is sus - pected, con trast urethrography is per formed. Ac cord ing to lit er a ture, ap prox i mately 90% of pa tients with blad der rup ture will have an as so ci ated pel vic frac ture, and man - age ment of these pa tients re quires close co op er a tion be - tween the uro logic and or tho pae dic teams. Uro logic trauma is more com mon in men, be cause of the lon ger male ure thra. Eighty-five per cent of blad der rup ture are extraperitoneal. Intraperitoneal rup tures are more rare. Intraperitoneal in ju ries are treated sur gi cally with di rect su ture re pair. Extraperitoneal rup tures are treated nonsur gi cally, re gard ing to lit er a ture da ta base 4. In our cases, all blad der in ju ries were extraperitoneal, treated sur gi - cally with same sur gi cal pro ce dure, team work with ex ter - nal fix a tion or in ter nal osteosynthesis of the an te rior pel - vic ring and pri mary re pairs of blad der or ure thral dis rup - tions or both. Blad der re pair de crease com pli ca tions by ap prox i mately 50% 17. Rea sons for this treat ment type can be found in the fact that or tho pae dic and uro logic sur - geons use the same sur gi cal ap proach (Pfannenstiel ap - proach) for plat ing of symphysis pubis and blad der repair. Blad der re pair will stop uri nary leak age from the injured blad der onto the or tho pae dic im plant (plate, screws). Pa tients with extraperitoneal rup tures treated con ser va - tively have higher rate of acute com pli ca tions (12-26%), and these to be more se ri ous (fis tula, fail ure to heal, sep - sis) 2. De spite ad e quate uri nary tract in jury treat ment, many pa tients showed dif fer ent uri nary com pli ca tions. These com pli ca tions were mi nor in 32,9% of pa tients and ma jor in 8,1% of all pel vic frac tures. Erec tile dys func tion along with uri nary in con ti nence is a com mon con se - quence of the pel vic frac ture, es pe cially com bined with dam age of pos te rior ure thra 11. Re duc tion and sta ble fix a - tion of pel vic ring are nec es sary to ob tain as good an a - tom i cal and func tional re sults as pos si ble. In ad e quate treat ment of pel vis frac tures leads to per ma nent dis abil - ity. Pel vic ring fix a tion in haemodynamically un sta ble pa tients with pel vic frac ture type B, C is per formed by ex ter nal fix a tion. Ex ter nal fix a tion can be used as de fin i - tive treat ment pro ce dure in haemodinamically sta ble pa - tients with pel vic frac ture type B, if the pel vic ring re duc - tion is achieved. Oth er wise, lit er a ture data sug ges tions for pel vic frac tures type B with dis rup tion of the symphysis pubis more than 2,5 cm is pu bic symphysis pubis re duc tion and fix a tion by plate in the same sur gi cal pro - ce dure with re pair of blad der and ure thra. Ex ter nal fix a - tion can be used as tem po rary treat ment method in type C

$Br. 1 Uri nary tract in jury as so ci ated with pel vic frac tures 13 A B C D E FIG URE 6.$ $DEFINITIVE REDUCTION AND FIXATION OF ANTERIOR AND POSTERIOR PELVIC COMPLEX HAD BEEN PER FORMED (E). pel vic frac tures.$ The con ver sion of ex ter nal to in ter nal fix a tion, af ter gen eral health sta tus sta bi li za tion and af ter fi nal uro logic pro ce dures, en ables pa tients to be ac tive.

The con ver sion of ex ter nal to in ter nal fix a tion, af ter gen eral health sta tus sta bi li za tion and af ter fi nal uro logic pro ce dures, en ables pa tients to be ac tive.

$There should be noted that ex ter nal fix a tion can be used as de fin i tive treat ment method in un sta ble type C pel vic frac tures and skel e tal trac tion is man da tory 19.$ $Pel - vic frac tures type C are ro ta tory and ver ti cally un sta ble and ad e quate ver ti cal sta bil ity can not be ob tained us ing ex ter nal fix a tion, be cause of pos te rior pel vic com$

5 Br. 1 Uri nary tract in jury as so ci ated with pel vic frac tures 13 A B C D E FIG URE 6. X-RAY OF PA TIENT IN JURED IN CAR AACCIDENT SHOW ING TYPE C2 PEL VIC RING FRAC TURE (A); MSCT SCAN OF THE SAME PA TIENT (B); CT CYSTOGRAPHY SHOWS CON TRAST EXTRAVASATION (C); UR GENT BLAD DER RE PAIR AND EX TER NAL FIX A TION OF PEL VIS HAD BEEN PER FORMED BY URO LOGIC AND OR THO - PAE DIC SUR GEONS (D); AF TER GEN ERAL HEALTH STA TUS STA BI LI ZA TION, 3 WEEKS AF TER PRI MARY SUR - GERY, DEFINITIVE REDUCTION AND FIXATION OF ANTERIOR AND POSTERIOR PELVIC COMPLEX HAD BEEN PER FORMED (E). pel vic frac tures. The con ver sion of ex ter nal to in ter nal fix a tion, af ter gen eral health sta tus sta bi li za tion and af ter fi nal uro logic pro ce dures, en ables pa tients to be ac tive. In our cases, Mitkoviæ type ex ter nal fixator had been used for pel vic ring fix a tion (Fig ure 7) 18. This de vice is high adapt able and ad e quate for tem po rary or de fin i tive pel vic fix a tion. There should be noted that ex ter nal fix a tion can be used as de fin i tive treat ment method in un sta ble type C pel vic frac tures and skel e tal trac tion is man da tory 19. Pel - vic frac tures type C are ro ta tory and ver ti cally un sta ble and ad e quate ver ti cal sta bil ity can not be ob tained us ing ex ter nal fix a tion, be cause of pos te rior pel vic com plex in - jury, and ad di tional skel e tal trac tion is re quired. Dis ad - van tages of ex ter nal fix a tion are that they do not pro vide pos te rior sta bil ity and can po ten tially in crease pel vic deformity and in crease pos te rior dis place ment in a pel vis with a ver ti cally un sta ble frac ture con fig u ra tion (Type C) 1,20. Lit er a ture data sug gests open re duc tion and sta ble in - ter nal fix a tion of both an te rior and pos te rior pel vic com - plex in haemodinamically sta ble pa tients to en able early ac ti va tion and to achieve good fi nal func tional and an a - tom i cal re sults 21. CON CLU SION Pel vic trauma as so ci ated with in jury of uri nary tract is very se vere con di tion re quir ing ur gent treat ment and team work of or tho pae dic and uro logic sur geons, with the same ob jec tive of their work. Pri mary re con struc tion of blad der and ure thra, catheterisation and drain age, per - formed by uro logic sur geons, and re duc tion and sta ble

SUM MARY POVREDE UROTRAKTA UDRU@ENE SA PRELOMIMA KARLICE Uvod: Povrede karlice i urotrakta su teške povrede, nastaju najše}e u saobra}ajnim udesima i pri padu sa visine.

6 14 S. Milenkovi} et al. ACI Vol. LXI A B FIG URE 7. EX TER NAL FIX A TION OF THE PEL VIS WITH MITKOVIC EX TER NAL FIXATOR (A,B). ex ter nal or in ter nal pel vic ring fix a tion, per formed by or - tho pae dic sur geons, are treat ment pro ce dures that give a chance for good an a tom i cal and func tional re sults. SUM MARY POVREDE UROTRAKTA UDRU@ENE SA PRELOMIMA KARLICE Uvod: Povrede karlice i urotrakta su teške povrede, nastaju najše}e u saobra}ajnim udesima i pri padu sa visine. Ovakve povrede zahtevaju hitan tretman i blisku saradnju urologa i ortopeda. Materijal i metode: Retrospektivna studija pacijenata sa povredama karlice i ekstraperitonealne povrede urinarnog trakta, koji su le~èeni hirurški na ortopedsko-traumatološkoj i urološkoj klinici KC Niš. Pacijenti su le~èeni operativno, timski u sklopu iste hirurške pro ce dure od strane ortopeda i urologa. Karlica je fiksirana spoljašnjom ili unutrašnjom fiksacijom. Za spoljašnju fiksaciju je koriš}en spoljašnji fiksator po Mitkovi}u, a za unutrašnju fiksaciju su koriš}ene rekonstruktivne plo~èe sa zavrtnjima. Tile-ova klasifikacija je koriš}ena za klasifikaciju povreda karlice, a za ocenu krajnjih funkcionalnih rezultata je koriš}en funkcionalni skor po Majeed-u. Rezultati: U periodu od do na klinici za ortopedsku hirurgiju i traumatologiju i na urološkoj klinici KC Niš je le~èeno 42 pacijenta sa povredama karliè~nog prstena, 30 muškaraca i 12 `ena, prose~ène starosti 53,69 godina ( od godina). U 80%, povrede karlice su nastale kao direktna posledica saobra}ajnog traumatizma. Prema klasifikaciji Tile-a, 9 (21,42%) pacijenta je zadobilo povredu karlice tipa A, 23(54,46%) povredu tipa B i 10 (23,80%) pacijenta povredu tipa C. Povrede urotrakta su dijagnostifikovane kod 9 (21,42%) pacijenata - 5(11,9%) sa povredom mokra}ne bešike, 3 (7,14%) sa povredom zadnje uretre i 1 (2,38%) sa povredom mokra}ne bešike i zadnje uretre. Zaklju~èak: Hitna rekonstrukcija ekstraperitonealne povrede urotrakta od strane urologa, repozicija i fiksacija karlice spoljašnjom ili unutrašnjom fiksacijom od strane ortopeda u sklopu iste hirurške pro ce dure predstavlja stan dard u le~èenju ovih povreda. Kljuè~ne reè~i: urinarni trakt, povrede, prelomi karlice REF ER ENCES: 1. Smith WR, Suzuki T, Tornetta P. Pel vic frac tures: Eval u a tion and acute man age ment. In: Schmidt AH, Teague DC, eds. Or tho pae dic Knowl edge Up date: Trauma 4. Amer i can Acad emy of Or tho pae dic Sur geons; p Santucci RA, Mcaninch JW. Blad der in ju ries: Eval u - a tion and man age ment. Bra zil ian Jour nal of Urol ogy 2000; 26(4): Cass AS. The mul ti ple in jured pa tients with blad der trauma. J Trauma 1984; 24: Starr AJ, Malekzadeh AS. Frac tures of the pel vic ring. In: Bucholz RW, Heckman JD, Court-Brown CM, eds. Rockwood& Green s Frac tures in adults 6th edi tion. Lippincott Wil liams& Wilkins; p Ter-Grigorian AA, Kasyan GR, Pushkar DY. Uro - gen i tal dis or ders af ter pel vic ring in ju ries. Cent Eu ro pean J Urol 2013; 66(3): Carroll PR, McAninch JW. Ma jor blad der trauma: mech a nism of in jury and uni fied method of di ag no sis and re pair. J Urol 1984; 132: Flancbaum L, Mor gan AS, Fleisher M, et al. Blunt blad der trauma: man i fes ta tion of se vere trauma. Urol ogy 1988;31: Tile M. Pel vic ring frac tures: should they be fixed? J Bone Joint Surg Br 1988;70: Majeed SA. Grad ing the out come of pel vic frac tures. J Bone Joint Surg Br 1989; 71(2): Wolinsky PR, Charlton MT. Dam age con trol or tho - pae dics: Prac ti cal is sues. In: Schmidt AH, Teague DC, eds. Or tho pae dic Knowl edge Up date: Trauma 4. Amer i - can Acad emy of Or tho pae dic Sur geons; p Pavelka T, Houcek P, Hora M, Hlavacova J, Linhart M. Uro gen i tal trauma as so ci ated with pel vic ring fractures. Acta Chir Orthop Traumatol Cech 2010;77: Figler B, Hoffler ED, Reisman W, Car ney K, Moore T, Feliciano D, Mas ter V. Multi-dis ci plin ary up date on pel vic frac ture as so ci ated blad der and ure thral in ju ries. In jury 2012; 43: Flint L, Cryer G. Pel vic frac ture: the last 50 years. J Trauma 2010; 69:

7 Br. 1 Uri nary tract in jury as so ci ated with pel vic frac tures Rout ML, Simonian PT, Defalco AJ, Miller J, Clarke T. In ter nal fix a tion in pel vic frac tures and pri mary re pairs of as so ci ated gen i to uri nary dis rup tions: a team ap proach. J Trauma 1996; 40(5): Pej~i} T, Lonè~ar Z, Rafailovi} D, A}imovi} M, D`ami} Z, Had`i Djoki} J. Gen i to uri nary in ju ries as so ci - ated with pel vic frac tures. Acta Chir Iugosl 2013; 60(2): Mor gan DE, Nallamala LK, Kenney PJ, Mayo MS, Rue LW 3 rd. CT cystrography: ra dio graphic and clin i cal pre dic tors of blad der rup ture. Am J Roentgenol 2000; 174(1): Cass AS, Luxenberg M. Man age ment of extraperitoneal rup tures of blad der caused by ex ter nal trauma. Urol ogy 1989; 33: Mitkovic M, Bumbasirevic M, Golubovic Z, Micic I, Mladenovic D, Milenkovic S. Lesic A, Bumbasirevic V, Pavlovic P, Karalejic S, Kuljanin G, Petkovic D. New con cept in ex ter nal fix a tion. Acta chir Iugosl. 2005; 52 (2): Dick son KF, Matta JM. Skel e tal de for mity af ter an - te rior ex ter nal fix a tion of the pel vis. J Orthop Trauma 2009; 23(5): Lindahl J, Hirvensalo E, Böstman O, Santavirta S. Fail ure of re duc tion with an ex ter nal fixator in the man - age ment of pel vic ring in ju ries: Long-term eval u a tion of 110 pa tients. J Bone Joint Surg Br 1999; 81: Milenkovi} S, Mitkovi} M, Saveski J, Mici} I, Mitkovi} M, Stameni} S. Sur gi cal treat ment of the un sta - ble type C pel vic in jury. Acta Chir Iugosl 2013; 60 (2): AC KNOWL EDGE This work was sup ported by the Mynistry for sci ence and ed u ca tion Re pub lic of Ser bia, pro ject III41017 Vir tual hu man osteoarticular sys tem and its ap pli ca tion in pre clin i cal and clin i cal prac tice.

TACTICAL COMMUNICATIONS HELMET (TCH)

TACTICAL COMMUNICATIONS HELMET (TCH) Fitting Instructions with Il lus trated Parts List 2006 GENTEX Cor po ra tion WARNING Proper strap ad just ment is cru cial for hel met sta bil ity and sound at ten