Post-partum management of severe pubic diastasis.

INTRODUCTION: Pubic symphysis diastasis during pregnancy is a rare complication which can present as pain with ambulation, urinary dysfunction, and pelvic instability. A consensus treatment does not currently exist between surgical and conservative management. The authors present a case of severe pubic diastasis which was successfully treated using a conservative pelvic binder. CASE REPORT: A 31-year-old female presented with severe lower back pain following the uneventful delivery of her fourth child. On radiograph, a pubic symphysis diastasis of 5.5 cm was noted and she was subsequently fitted with a pelvic binder on post-partum day 3. She experienced a full range of motion and was pain free at six-week follow-up, with a diastasis of 2.1 cm present. At one year and three-month follow-up, the patient presented with a diastasis of 2.4 cm and continued to have full range of motion and mobility. CONCLUSION: This case contributes to the literature in showing that conservative treatment of pubic diastasis could be considered in cases where separation has exceeded normal physiologic limits.

Wire in the hole: a case series of eroded intrapubic wire sutures causing genitourinary complications in the bladder exstrophy complex.

Bladder exstrophy and cloacal exstrophy are rare congenital defects of the genitourinary tract that require complex surgical reconstruction. Malrotation of the bony pelvis causes a characteristic diastasis of the pubic symphysis, which is surgically reduced at the time of initial bladder closure. For a successful primary closure without tension such that the bladder can be placed deep within the pelvis, pelvic osteotomy is often used. However, alternative techniques have been utilized to bring the pubic rami into apposition. The authors present four bladder/cloacal exstrophy patients in which an intrapubic wire was used for pubic apposition, resulting in significant genitourinary complications.

Computed tomography-based three-dimensional visualisation of bone corridors and trajectories for screws in open reduction and internal fixation of symphysis diastasis: a retrospective radiological study.

INTRODUCTION: Typical stabilisation of pelvic open book injuries consists of plate fixation of the symphysis. No previous literature has been published about the evaluation of screw placement and their trajectory with four oblique 4.5 mm screws using a four-hole plate in symphysis diastasis. The aim of this study was to define insertion points and angles of trajectory for crossed screw placement regardless of any plate design based on an analysis of three-dimensional computed tomography data sets. METHODS: One hundred human pelvic CT data sets were collected. Unilateral and bilateral placements of crossed 4.5 mm screws were simulated. Primary outcome measure was successful simulated screw placement without cortical breach. Secondary outcome measures included the anatomical measurements of the screw positions. RESULTS: Simulated screw placement of two oblique screws on each side of the pubic symphysis without cortical breach was achieved in all (100 %) cases. There were a total of 400 screw simulations. Medial screws were longer, lateral screws had higher coronal angles, and the distance between both screws was higher on the right side (p < 0.001 each). The lengths of the right lateral, right medial, left lateral, and left medial screws were 44.9, 65.8, 45.4, and 67.4 mm, respectively. The sagittal angles to the dorsal surface area of the pubic rami were 10.5°, 11.1°, 9.0°, and 11.0°. The coronal angles to the vertical axis of the symphysis measured 39.5°, 16.0°, 33.8°, and 16.8°. The distances between these screws and the medial edge of the pubic crest were 33.5, 8.6, 29.5, and 7.3 mm. Furthermore, certain sex- and side-related differences were noted. CONCLUSIONS: This series provides results about the feasibility and a detailed anatomical description of crossed screw placement. This is of special interest in pelvic surgery for choosing the entry points, safe screw channel parameters, and trajectories.

[Traumatic symphyseal rupture by vaginal delivery,report of a rare case]. / Traumatická ruptura spony pri vaginálním porodu - kazuistika.

OBJECTIVE: This case report draw attention symphysis pubic dysfunction and injury pelvic girdle by vaginal delivary (in our case compliated by dystokia shoulders), mainly its diagnostic, prediction and treatment. DESIGN: Case report. SETTING: Department of Obstetrics and Gynecology. Hospital Ceská Lípa. CASE REPORT: We report a case of a 31 years old woman, who gave birth for the second time with rupture of symphysis after delivery. Childbirth was complited by dystokia shoulders and patient was treated with external fixator. CONCLUSION: Pregnancy is a time of many physiological changes, these changes impact the musculosceletal system, which can develop a variety of problems, such es back pain, separation of the pelvic bones, transient osteoporosis and tendonitis. Effective management of treatment remains difficult to determine because of a variation in reported occurence rates and symptomatology. The most of cases are solved conservatively. This case report is extreme case of birth injury pelvic skeleton and it was necessary for surgery with an external fixator.This cases should be not to underestimate it and to treat it in interdisciplinary cooperation.

The pubic midline exposure for symphyseal open reduction and plate fixation.

BACKGROUND: Open reduction and plate fixation of the disrupted symphysis pubis is commonly performed through a horizontal Pfannenstiel incision. Certain clinical situations that complicate the soft tissue conditions of the lower abdomen may make the Pfannenstiel incision a less appealing option. We report on the use of a vertical pubic area midline skin incision in a series of patients undergoing open reduction and plate fixation of their traumatically disrupted symphysis pubis. MATERIALS AND METHODS: Institutional Review Board approval was obtained for a retrospective chart review of the charts of 25 patients treated between September 2011 and October 2012. Their charts were reviewed for patient age, gender, body mass index (BMI), pelvic injury type (as classified by Young and Burgess), mechanism of injury and associated traumatic injuries. The depth of the approach was estimated using the pelvic computed tomography (CT) scan. Details from the operative procedure were recorded, as was the length of follow-up and any perioperative complications. RESULTS: Twenty-five patients were eligible for inclusion during the defined study time period between September 2011 and October 2012. The patients' average age was 55.8 years (range 25-91). All patients were males. The average BMI was 29.3 (range 18.8-43.8). The depth measured on the axial pelvic CT scan from skin to symphysis was 57.6 mm (range 35.2-90.2 mm). Five of 25 patients had an isolated pelvic ring injury without other associated injuries. The injury pattern was APC2 in 18, APC3 in 3, LC2 in 2, LC3 in 1 and VS in 1 patient(s) [anterior posterior compression (APC), lateral compression (LC), vertical shear (VS)]. Urologic procedures were performed in the same surgical setting in four patients. The average blood loss was 244 ml (range 150-400 ml). The average follow-up was 2.5 months (range 1-12 months). Perioperative issues were noted in two patients. One patient died within a month of surgery as a result of his associated traumatic injuries. One patient developed a deep infection. CONCLUSION: The pubic midline skin exposure is a feasible alternative to the Pfannenstiel incision for open reduction and plate fixation of the pubic symphysis. LEVEL OF EVIDENCE: IV, Retrospective case series.

Pubic symphysis diastasis with urinary incontinence: collaborative surgical management.

Pubic symphysis diastasis during obstetric delivery occurs rarely. Symptoms usually respond to conservative management. A nulliparous 39-year-old delivered spontaneously with an audible pop noted. Pubic symphysis diastasis of 4.6 cm was diagnosed on pelvic X-ray. She developed severe pain with ambulation and stress urinary incontinence. After neither of these symptoms improved significantly in response to conservative management, the patient underwent open reduction internal fixation with plating of her pubic symphysis, and bladder neck sling placement using autologous rectus fascia. Postoperatively she experienced urinary retention, which resolved with continuous bladder drainage for 1 week. Both her urinary incontinence and pain resolved, and she had resumed normal activities 3 months following her surgery. Pubic symphysis diastasis is a rare obstetric complication with a paucity of literature to guide its management. A coordinated multidisciplinary approach to management is necessary when multiple organ systems are involved.

Spontaneous urinary voiding of metallic screws in a patient with symphyseal plating for type II pelvic ring disruption.

With rapid advancement in surgical techniques and improvement in implant materials, rate of internal fixation for pubic symphyseal disruption in rotationally and vertically unstable pelvic ring injuries has increased. Among various modes of implant failure, screw/plate breakage and loosening are common complications following unstable fixation. Migration of loose screws into the urinary bladder has been reported as an extremely uncommon complication of pubic symphyseal plating. Here we present a case report of a 52-year-old female who presented with asymptomatic passage of screws in her urine following migration into the bladder, 2 years after symphyseal plating for pubic diastasis in an anteroposterior compression pelvic ring injury.

Postpartum Symphysis Pubis Diastasis: A Case Report.

The pubic symphysis is a midline, non-synovial joint connecting the right and left superior pubic rami. The joint allows very limited movement of approximately 0.5-1 mm. Under hormonal stimulation during pregnancy, the widening of the symphysis pubis and sacroiliac joints occurs. Pubic symphysis diastasis is defined as the widening of the pubic joint of >10 mm. It is a rare complication of vaginal childbirth for which no gold standard treatment has been defined. Most cases are treated conservatively. A case of pubic diastasis in a 24-year-old G5P2A2L1 following vaginal delivery is reported. Management consisted of simple conservative treatment, which was sufficient in achieving symptomatic relief. Keywords: case reports; pelvic pain; pubic symphysis diastasis.

[Research progress of pubic symphysis diastasis].

Objective: To review the research progress of pubic symphysis diastasis and provide effective reference for orthopedic surgeons in the diagnosis and treatment of pubic symphysis diastasis. Methods: The anatomy, injury mechanism, treatment, and other aspects of pubic symphysis diastasis were summarized and analyzed by reviewing the relevant research literature at domestically and internationally in recent years. Results: The incidence of pubic symphysis diastasis is high in pelvic fractures, which is caused by the injury of the ligaments and fibrocartilage disc around the pubic symphysis by external force. The treatment plan should be individualized according to the pelvic stability and the needs of patients, aiming to restore the stability and integrity of the pelvis and improve the quality of life of patients after surgery. Conclusion: At present, the research on pubic symphysis diastasis still needs to be improved. In the future, high-quality, multi-center, and large-sample studies are of great significance for the selection of treatment methods and the evaluation of effectiveness for patients with pubic symphysis diastasis.

Management of chronic symphysis pubis pain following child birth with spinal cord stimulator.

The case of a 39 year old woman who had diastasis of pubic symphysis following childbirth and later developed severe chronic neuropathic pain and disability is presented. She received extensive surgical and medical treatment for 6 years with no improvement of symptoms. The VNRS (Visual Numerical Rating Scale) pain score was 7/10 or more most of the time. This was quite disabling in terms of her quality of life. A spinal cord stimulator was inserted after failure of other modalities of pain management which resulted in dramatic improvement in the quality of life measured with SF-36 questionnaire. Her pain score became 0/10 VNRS and she was free from opioids and psychotropic medications within 3 months post insertion. Spinal cord stimulator can be considered for the management of pain due to diastasis of pubic symphysis, not amenable to other therapies.

Chronic Pelvic Diastasis 22 Years After Twin Natural Delivery: A Case Report.

CASE: We present here a case of chronic pelvic separation 22 years after twin natural delivery in a 49-year-old woman surgically treated with anterior and posterior stabilization. The functional and radiological recovery after a 4-year follow-up was extremely good. CONCLUSION: Postpartum pubic symphysis diastasis is a rare but dreaded complication of natural delivery. Nonoperative treatment is still considered the gold standard. However, when pain persists despite nonoperative treatment and when a pelvic radiograph reveals a pubic diastasis greater than 2 cm, surgery is recommended. In the case of low back pain because of sacroiliac joint lesions, posterior fixation is indicated.

A case-control study of clinical characteristics and risk factors of symptomatic postpartum pubic symphysis diastasis.

Postpartum pubic symphysis diastasis (PPSD) refers to the separation of pubic symphysis after delivery. It is typically diagnosed based on clinical symptoms and radiologic findings. This study tried to assess clinical characteristics and risk factors of PPSD. This was a nested case-control study matched for year of delivery and gestational age at delivery using a retrospective cohort of women who delivered vaginally at a single institution. The incidence of PPSD was 0.156% (33/21,131). The incidence rate increased from 0.08% (7/9328) in 2000-2004 to 0.13% (9/7138) in 2005-2009 and to 0.36% (17/4665) in 2010-2016, simultaneously with an increase of maternal age (30.7 ± 3.5 years in 2000-2004 to 31.8 ± 3.8 years in 2005-2009 and 32.8 ± 3.8 years in 2010-2016). Nulliparity was associated with a higher incidence of PPSD (81.8% in cases vs. 57.6% in controls, p = 0.01). Other factors including pre-pregnancy body mass index, weight gain during pregnancy, gestational diabetes, induction of labor, duration of labor, epidural anesthesia, vacuum-assisted delivery, episiotomy, neonatal sex and birth weight failed to show difference between the two groups. In short, the incidence of PPSD increased with time along with an increase of maternal age. Nulliparity was the only significant risk factor for PPSD.

Pubic Diastasis in Polytrauma Patients: Traumatic or Congenital?: A Report of 2 Cases.

CASE: We report 2 patients who were involved in high-velocity road traffic accidents. Both these patients had congenital pubic diastasis with very subtle clinical and radiological signs that were misdiagnosed as posttraumatic diastasis on initial radiographic evaluation. CONCLUSION: Trauma surgeons should be aware of this anomaly because congenital pubic diastasis could present without any major clinical signs and could easily be mistaken for a traumatic diastasis.

Clinical and radiological short-term outcomes of pubic symphysis diastasis treated with modified pedicle screw-rod fixation.

PURPOSE: Pubic symphysis diastasis with an incidence of approximately 20% in pelvic fractures is a severe lesion which needs to be treated properly. The objective of this retrospective study was to describe and evaluate the clinical and radiological outcomes including its advantages and limitations of this modified minimal invasive technique. METHODS: Totally 29 patients with pubic symphysis diastasis, with or without posterior ring instability, were treated by modified pedicle screw-rod fixation (modified PSRF) between January 2010 and December 2016. The duration from injury to surgery, operation time, intraoperative blood loss as well as complications were recorded. During follow-up, the functional outcomes were assessed according to the Majeed evaluation criteria 1 year postoperatively. The evaluation of the postoperative reduction quality was carried out according to Matta criteria. RESULTS: According to Tile classification, there were 9 cases of Type B1 underwent only anterior-modified PSRF and 20 cases of Type C1 experienced anterior-modified PSRF combined with posterior fixation. The duration from injury to operation, operation time and intraoperative blood loss were 3.27 days (range 1-6 days), 42.07 min (range 38-45 min), and 46.14 ml (range 40-55 ml). The results of reduction quality were rated as excellent in 16, good in 11 and fair in 2 based on Matta criteria. The Majeed functional scores ranged from 68 to 95 and there were excellent in 15, good in 12 and fair in 2. No patients experienced incision infection. Slight loosening of middle-two screws was verified during follow-up in one patient. Two patients underwent femoral nerve palsy. Irritation to the LFCN was detected in four patients. CONCLUSIONS: Modified PSRF can be performed as an alternative to manage pubic symphysis diastasis due to its merits of minimal invasive, less blood loss, less soft tissue injuries as well as shorter operation time, even with the early weight-bearing. TRIAL REGISTRATION: Researchregistry3905.

Severe separation of the pubic symphysis and prompt orthopedic surgical intervention.

BACKGROUND: The incidence of pubic symphysis separation during delivery is 1 in 300 to 1 in 30,000 pregnancies, and it can cause a variety of problems such as pain, bladder dysfunction, and difficulty ambulating. There is no consensus on how to treat pregnancy-related pubic symphyseal separation. CASE: A patient, gravida 1 para 1, who underwent vacuum-assisted vaginal delivery was found to have a severe vaginal sidewall laceration and a 6.2-cm symphyseal disruption. The patient was treated with external fixation of an open book pelvis and physical therapy. She was discharged to home on postpartum day 4, voiding spontaneously and ambulatory with a walker. CONCLUSION: Aggressive treatment of severe pubic symphysis separation with external fixation resulted in early ability to ambulate, void, and care for self and baby.

Urethral Trauma Following Pelvic Fracture From Horseback Saddle Horn Injury Versus Other Mechanisms of Pelvic Trauma.

OBJECTIVE: To examine the rate of urethral trauma and pubic symphysis diastasis in saddle horn injury, which occurs when horseback riders are bucked into the air and land with their perineum striking the rigid saddle horn, compared to pelvic fracture from other mechanisms. METHODS: A retrospective review was performed of male patients presenting to our level-1 trauma center with pelvic ring fractures between January 1, 2001 and December 30, 2016. Demographics, injury severity score, mechanism of injury (saddle horn vs other), pubic symphysis diastasis, and lower genitourinary (GU) injuries (bladder and urethra) were identified in the trauma registry. Chart review confirmed accuracy of lower GU trauma. RESULTS: A total of 1195 males presented with pelvic ring fractures, average age 43 years (SD 19 years). Of these, 87 of 1195 (7%) presented with lower GU injuries. Saddle horn injuries had a higher rate of lower GU injuries, 12/60 (20%) versus 75 of 1135 (7%) [P = .001]. In those with lower GU injuries, 47 of 87 (54%) had urethral injury. The rate of urethral injury was significantly higher in the saddle horn cohort, 10 of 12 (83%) versus 37 of 75 (49%) [P = .03]. Furthermore, rate of pubic symphysis diastasis was higher amongst saddle horn injuries, 12 of 12 (100%) versus other mechanisms 39 of 75 (52%) [P = .001]. CONCLUSION: We found that urethral injury and pubic symphysis diastasis were higher in patients with saddle horn injury compared to other mechanisms of pelvic ring disruption. Clinicians should be aware of these associations when treating pelvic fracture following equestrian injuries.

Combined treatment with vacuum sealing drainage, TopClosure device, and Ilizarov technique for traumatic hemipelvectomy: A rare case report of successful repairing of large-size soft tissue defects.

RATIONALE: Traumatic hemipelvectomy is a rare but lethal catastrophic injury. PATIENT CONCERNS: A case of a very young child with open fracture of left sacroiliac joint dislocation and pubic symphysis diastasis, suffered from a severe large-size soft tissue defects. DIAGNOSIS: Traumatic hemipelvectomy. INTERVENTIONS: Complete amputation was performed and three kinds of surgical techniques including regulated negative pressure-assisted wound therapy (RNPT), TopClosure device, and Ilizarov technique were jointly utilized to secure closure in the further revisions of the soft tissue injury and reconstruct reconstructive surgery. OUTCOMES: Six months after hospital discharge, the patient was able to ambulate with a single limb and a prosthesis and she is independent in many activities of daily living currently. LESSONS: We report this case to share experience with other clinicians in the management of this deadly extensive defects after traumatic hemipelvectomy in patients.

Risk factors for erectile dysfunction in patients with urethral strictures secondary to blunt trauma.

INTRODUCTION: Erectile dysfunction (ED) is a well-known consequence of pelvic fracture, particularly in cases involving urethral injury. There are several risk factors that may be related to ED. However, no systemic approach is used to assess erectile function secondary to urethral trauma. AIM: To investigate ED associated with urethral injury secondary to pelvic fracture and perineal trauma. METHODS: Forty patients with traumatic urethral strictures secondary to blunt traumatic impact episode to the pelvis or perineum were included in our study. Pelvic fractures and urethral strictures were categorized according to injury types and radiological findings. All patients underwent nocturnal penile tumescence (NPT) monitoring, dynamic color-duplex Doppler ultrasonography (D-CDDU) before surgery. NPT monitoring was conducted again after surgery. MAIN OUTCOME MEASURES: The events of NPT and D-CDDU were recorded. RESULTS: In all patients, 11 had organic ED demonstrated by NPT. Vascular pathology was identified in three of 11 patients (27%). The peak systolic velocity of cavernosal artery was lower in patients with pubic diastasis in comparison to those without diastasis (P < 0.05). Significant changes in penile length and circumference were noted in posterior urethral injury compared with anterior urethral injury during erection (P < 0.05). The erectile duration time has a similar statistical difference in two groups mentioned above. However, no significant difference could be observed in the end-to-end anatomosis procedure before and after surgery (P > 0.05). CONCLUSIONS: The pelvic fracture type, especially pubic diastasis, is a risk factor for ED following urethral injury. Location of the stricture is also a risk factor for subsequent erectile dysfunction.

External fixation of pubic symphysis diastasis from postpartum trauma.

Pubic symphysis diastasis is recognized as a possible complication of pregnancy. When this occurs, pubic symphysis diastasis may cause anterior widening and loss of stiffness within the pubic symphysis, causing potential instability in the pubic joint. The persistent loss of reduction can cause substantial disability in postpartum women. Pubic symphysis diastasis has previously been treated conservatively using a pelvic girdle and bedrest with some success. When a diastasis >3 cm is present, however, surgical intervention may be needed to preserve the integrity of the pubic symphysis joint. To date, most surgical procedures for reduction of pubic symphysis diastasis have been via internal fixation with plates and screws on the superior pubic rami. Although internal fixation provides good structural support, this method would be inadequate if a postpartum pubic symphysis diastasis patient has significant reproductive organ damage, due to the risk of soft tissue infection or osteomyelitis. External fixation is an alternate method of pubic symphysis diastasis treatment that has not received significant attention in the literature to date. We present the following case report to highlight a novel use of a pelvic frame external fixator for treatment of a severe postpartum pubic symphysis diastasis with organ damage. This article outlines a treatment alternative to internal fixation for cases of pubic symphysis diastasis with a contaminated pelvic environment.