- Discussion:
- anterior injury may be through symphysis or thru pubic rami unilaterally or bilaterally;
- symphysis disruption may also occur with pubic rami fractures;
- posterior injury: degree of SI joint disruption depends on the energy sustained during the trauma;
- sacrotuberous and sacrospinous ligaments may be disrupted;
- when posterior SI ligaments are disrupted the open book injury is considered unstable;
- Classification of AP Pelvic Fractures:
- diastasis > 1 cm represents pubic instability;
- however, in female patients that have had children, this may be a normal width;
- diastasis of > 2.5 cm represents ligamentous damage at
SI joint;
- references:
-
Does 2.5 cm of symphyseal widening differentiate anteroposterior I from anteroposterior compression II pelvic ring injuries?
-
Stress radiograph to detect true extent of symphyseal disruption in presumed anteroposterior compression type I pelvic injuries.
-
associatted injuries:
- impotence:
- occurs in 37 % of diastasis patients as result of injury of nervi erigentes or interruption of the penile blood supply;
-
bladder or urethra injury:
- may occur in 50% pts w/ a straddle frx;
-
posterior injury:
- posterior lesion may be frx of
ilium,
sacral frx, or
SI dislocation, usually w/ portion of ilium remaining attached to main sacral frag;
- do not confuse an "isolated pubic ramus frx" w/
LC-I injury pattern;
- Work Up: Physical Exam and
Radiographs (
reduction of pelvic volume)
- Non Operative Treatment:
- generally pubic rami fractures do not require surgical treatment;
- should be considered for anterior diastasis of less than 2.5 cm;
-
example:
- this patient sustained a 2.3 cm diastasis following a parachute injury;
- one week after injury the diastasis closed down to 1.6 cm and did well with non operative treatment;
- Indications for Plating:
- open book fracture, more than 2.5 cm;
- ORIF may also be indicated when there has been concomitant genitourinary injuries;
- ref:
Internal Fixation in Pelvic Fractures and Primary Repairs of Associated Genitourinary Disruptions: A Team Approach.
- avoid operating on patients who have previously been operated on for abdominal or urologic injuries;
- fascial planes may be disrupted placing the bladder and other visceral structures at risk during symphsis pubis repair;
- in these cases consider
external fixation;
- PreOp Planning:
- need to determine the amount of
posterior instability;
-
vertical shear injury
- these frx are unstable and while acceptable reduction of posterior displacement may be obtained by
anterior plating, recurrent displacement posteriorly typically occurs;
- posterior or verticle displacement may occur despite application of traction or an
external fixator;
- some authors recommend double plating inorder to provide additional stability;
- hence posterior stabilization is required following anterior plating;
-
concomitnat repair of pelvic frx and
GU injuries:
- pt is positioned supine on a flouro table;
- ref:
Internal Fixation in Pelvic Fractures and Primary Repairs of Associated Genitourinary Disruptions: A Team Approach
- Anterior Fixation Methods:
- anterior fixation alone is indicated for
type II fractures, where as
type III require anterior fixation along with
posterior fixation;
-
treatment options:
-
Orthomed pelvic reduction clamps (
temporary for reduction of pelvic volume)
-
External Fixation:
- indicated for SI diastasis or pubic ramus frx which cannot be treated by open reduction or screw fixation;
- such as may occur w/ suprapubic cystostomy tube or open frx;
-
Open Reduction and Plate Fixation:
-
types of anterior plates:
- indicated for pubic diastasis greater than 2.5 cm;
-
Retrograde Medullary Superior Ramus Screw:
- indicated for superior ramus fractures which occur along w/ an ustable
posterior injury
Pelvic ring disruptions with symphysis pubis diastasis. Indications, technique, and limitations of anterior internal fixation.
Stress fractures of the pubic ramus. A report of twelve cases.
The Symphysis Pubis: Anatomic and Pathologic Considerations.
Impotence after fractures of the pelvis.
Internal fixation of symphyseal disruption resulting from childbirth
Open reduction and internal fixation of a traumatic diastasis of the pubic symphysis: one-year radiological and functional outcomes
Complications of Anterior Subcutaneous Internal Fixation for Unstable Pelvis Fractures: A Multicenter Study
Management outcomes in pubic diastasis: our experience with 19 patients.
The long-term clinical outcome after pelvic ring injuries
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