Introduction The purpose of this paper is to describe our management of complex fractures of the distal radius and ulna using a combined type of stabilization, external with a Pennig fixator, internal with radial augmentation with plate. The patient have substained a several general trauma or an high energy scheletral trauma upper limbs.

Treatment In a period from 24 july 2002 to today 8 october 2004 (26 months) we have treated surgically 93 wrists with distal radial fractures in 85 patient.

4 patients bilaterally, 3 patients have substained a secondary reprease for lacking the initial reduction and 2 in two programmed timing.

46 wrists with radial internal fixation single or double plate (in one case trhee plate)

12 plate with pin or single screw in augmentation

3 cases with only screw artroscopically assisted

14 cases with only external fixator with or without pin

18 wrist with a combination of radial internal fixation (plate) and external fixation with Pennig, in complex distal radial-ulna fracture (2 exposed)

In 5 wrists there were associated and treated navicular fracture or intracarpal ligaments injury

1 pazient have sustained an ipsilateral forearm fracture, epiphiseal distal radial fracture, trans scapho-lunate dislocation and controlateral transcapho-lunate dislocation

1 patient have sustained ipsilateral navicular-fisrt metacarpal-radial and ulna fracture

The most patients (...) have been treated from the first Author.

The patients were controlled from minimum of 6 month up a maximum of 39 months

We have adapted in our evaluation the Dash score system

The main problem, in the follow up results is a lack of prono-supination that stresses the importance of a perfect reduction of distal radio-ulnar joint to begin early a phisiotherapy

Clinical results In conclusion our experince in timing of treatment indicate that is important fixate the lesions earlier, whenever the priority of treatment on severly injured pazients are respected

We believe that a combination of the two fixation system allow an optimal external stabilization in the first week (So the terapist can move the patients in intensive care room). Secondary the internal fixator allows an anatomical reduction with a stable fixation in the secondary kinesiterapeutic time protocol of high energy trauma to distal forearm, in particular in politraumatized patients is:

- closed reduction and short cast or external fixator if exposed or severe instable, on the day of injury during or just following generally stabilization

Introduction A complex challenge to trauma surgeon is the choice of clinical pathway management in hemodynamic unstable patients with pelvic ring disruption and potential intraperitoneal or other extrapelvic hemorrhage.

Aim of the study In multi-trauma bleeding patients with pelvic ring injuries causing increased pelvic volume, the main source of hemorrhage is the fracture itself; in biomechanical stable the priority is to search and to treat extrapelvic sources of hemorrhage; CESCT is critical in the selection of appriopriate therapeutic approach in the case of bleeding pelvic injury.

Material and Methods Patients admitted as major trauma are immediately evaluated by a multidisciplinary team in a dedicated room where ABC resuscitation, plain radiographs, abdominal ultrasound/DPL may be all performed. The comprehensive Tile pelvic disruption classification combines the mechanism of injury and the degree of pelvic stability. Previous works correlated pelvic fracture pattern with the risk of pelvic fracture hemorrhage. Classically, APC and VS mechanisms were associated with pelvic hemorrhage and LC mechanims with abdominal organ injuries. In this work we included in group A patterns of pelvic fracture where increased pelvic volume and major ligamentous disruption (Tile B1, B3 and C or APC and VS), Patterns of pelvic fractures with low risk of bleeding, such as those without ligament lacerations (Tile A) or with reduced pelvic volume (Tile B2 or LC) or isolated acetabular fractures, have been included in group B.

Results Between October 2002 and January 2004, significant bleeding was observed in 87 of 142 pelvic fractures (61.26%).

Thirty-seven of 87 (42.5%) had a pelvic fracture pattern attributable to group A and 50 to group B

All patients included had multiple sites of bleeding, but predominant hemorrhage from pelvic fracture was observed in 87% of group A patients and in only 6% of group B, while predominant hemorrhage from extra-pelvic sites was identified in 94% of group B and in only 13% of group A (p< .001).

Conclusion Pattern of pelvic seems to be suggestive of the predominant site of bleeding; early application of measures of temporary pelvic stabilization should be considered a completion of resuscitation protocol; CESCT is the best diagnostic tool to choice the appropriate way to manage bleeding pelvic injuries and associated intraperitoneal injuries; availability of equipped CT scan and angiographic suitesand of short response time interventional radiologist is a crucial point for this diagnostic and therapeutic work-up.