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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
                  - failure to recognize posterior injury is a major cause for anterior plate fixation failure;  
            - 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
                    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;
            - ref: Anatomic relationship between the spermatic cord and the pubic tubercle: are our clamps injuring the cord during symphyseal repair? 
    - exposure of symphysis:
            - identify the pubic eminences on either side of the symphysis;
            - the anterior portion of the symphysis is cleared of soft tissue;
            - ref: Does Removal of Symphyseal Cartilage in Symphyseal Dislocations Have Effect on Final Alignment and Implant Failure?
    - 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
                          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 rectus & 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

Early failure of symphysis pubis plating.

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?