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Wheeless' Textbook of Orthopaedics

Anterior Pelvic Injuries: Open Surgical Approach w/ Plates 


- See: Anterior Plate Fixation Methods

- Indications:

    - open book pelvis injury w/ greater than a 2.5 cm pubic diastasis;
    - note that fixation of pubic rami fractures can be much more complex than the fixation of a simple diastasis;
    - controversies:
            - posterior injury and need for SI joint fixation
            - urinary injuries:
                  - management of anterior symphyseal injuries w/ concomitant urethra injury:
                  - consider anterior plating of symphyseal injuries at either the time of supra-pubic catheter insertion or within a 24-48 hour windonw;
                  - after 48 hours, risk of infection is unacceptably high;

- Preoperative Considerations:  
    - ensure that bladder and urethral injury has been considered;
    - repairs can be performed by a urologist using the same exposure prior to symphyseal reduction;

- Open Surgical Approach:
    - pt needs to be positioned supine on flouro table;
            - be sure that the flouro machine can visualize the pubis;
            - often the patient needs to be moved downward on the flouro table;
    - Pfannenstiel incision:
            - indicated when the fracture is located medial to the iliopectineal eminence;
                  - fractures lateral to this prominence endagers the vascular sheath, thru the Pfannenstiel approach;;
                         - in this case, use the ilioinguinal approach, which is indicated for superior ramus frx lateral to the iliopectineal eminence;
            - transverse incisions offer execellent visualization;
            - horizontal incision about 15-20 cm in length and 2 cm above symphysis;
            - at the lateral edges of the incision take care to avoid the spermatic cords (or the round ligament in females);
            - verticle incision:
                  - is an alternative to the Pfannenstiel, in cases of concomitant abdominal trauma;
    - identification of the rectus:
            - normally, the rectus abdominus muscle tendons insert onto the anterior aspects of the pubis.
            - in acute case, rectus abdominis muscle has usually been avulsed and dissection is easy;
            - in chronic cases this dissection can be very difficult because of scar;
            - if the rectus has not be avulsed, then incise it, leaving a cuff of tissue attached to the pubis for later wound closure;
            - alternatively consider a verticle incision between the halves of the recti muscles, leaving the muscles attached to the pubis;
            - ref: Refixation of the M. recti abdomini on the symphysis in traumatic pubis symphysis disruption. Reconstruction to the original anatomic situation
    - identification of the spermatic cords (and inferior epigastric artery):
            - the dissection proceeds laterally, until the external inguinal rings and the spermatic cords are identified;
    - exposure of symphysis:
            - identify the pubic eminences on either side of the symphysis;
            - the anterior portion of the symphysis is cleared of soft tissue;
    - hazards:
            - surgeon must stay on the skeletal plane to avoid injury to bladder;
                  - the bladder lies directly behind the symphysis pubis, and in males the bladder neck is attached to the posterior surface of the pubis by puboprostatic ligaments;
                          - females in contrast, have a bladder that is in more contact with the pubococcygeal portions of the levator ani muscles;
                  - with previous surgery or an old injury, the bladder may be scarred to the undersurface of the rectus and the symphysis pubis;
            - note proximity of symphysis both to spermatic cord & to NV structures;


- Reduction:
    - reduction of the symphysis is usually easy in the acute case;
    - assistant may apply pressure over each iliac crest or an external fixator can be applied;
    - reduction clamps:
          - orthomed pelvic reduction clampss
          - Farabeuf and Lane clamps and large pointed pelvic reduction clamps;
          - large pointed reduction clamps are applied into the obturator foramen and closed;
                - large pointed reduction clamp can be placed onto each pubic tubercle or through holes drilled in the bone;
                - expose the medial obturator foramen and application of pelvic reduction forceps thru the medial aspect of the foramen;
          - alternatively two 4.5 mm screws are inserted into the anterior symphysis and farabeuf clamps are applied over these screws;
          - external fixator can also be applied to assist with the reduction;
    - hazards: 
          - during the reduction care must be taken to avoid trapping bladder or urethra in the symphysis when closing the clamp;
          - ensure that the ends of the symphysis are opposed;
          - surgeons gloved finger is passed into the space of Retzius;
          - foley catheter is palpated (in the bladder) and continued urine output is noted;
    - reference:
          - A technique for reducing diastasis of the symphysis pubis.


-
Anterior Plate Fixation Methods



Diastasis of the Symphysis Pubis: Open Reduction Internal Fixation

Radiological analysis, operative management and functional outcome of open book pelvic lesions: A 13-year cohort study

Implant retention and removal after internal fixation of the symphysis pubis.

Is fixation failure after plate fixation of the symphysis pubis clinically important?




Original Text by Clifford R. Wheeless, III, MD.

Last updated by Data Trace Staff on Monday, July 22, 2013 12:27 pm