- Discussion:
- anterior injury may be thru 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:
- 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;
-
associatted injuries:
- impotence:
- occurrs 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:
- 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.
ML Chip Routt MD, PT Simonian MD, AJ Defalco MD, J Miller MD, and T Clarke MD.
- 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.
ML Chip Routt MD, PT Simonian MD, AJ Defalco MD, J Miller MD, and T Clarke MD.
- Fixation Methods:
-
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;
Advances in 1985--General Orthopaedics: Pelvic Ring Disruptions With Symphis Pubis Diastasis: Indications, Technique, and Limitations of Anterior Internal Fixation.
Internal Fixation of the Lumbar Spine--General Orthopaedics: The Symphysis Pubis: Anatomic and Pathologic Considerations.
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.
A technique for reducing diastasis of the symphysis pubis.
Talbot D.
Stuart PR.
Milne DD.
Journal of Bone & Joint Surgery - British Volume.
71(5):865-6, 1989 Nov.
