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1/13/2014
Symphysis Pubis Injuries
Sandy Schwartz, MD - UCSanDiego
Tim Achor, MD – UTHouston
Mike Gardner, MD - WashUStLouis
Chip Routt, MD - UTHouston
Patient Example
•
•
•
•
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52yo Male
MCA
Pelvic Pain
Complete SI
Complete SPubis
•
•
•
•
Anatomy – Injury
Initial Treatment
Definitve Treatment
Potential Problems
Patient Example
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1/9/2014
SYMPHYSEAL INJURIES
Injury Patterns, Evaluation,
Imaging, and Indications
Alexandra Schwartz, MD
University of California, San Diego
DISCLOSURES
• Spouse Zimmer
• Honorarium AONA
• Overall incidence 3%
• 25% of poly-trauma patients
• 42% fatal traffic-related injuries
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INJURY PATTERNS
PELVIC CLASSIFICATION
Letournel
• Anatomical
Tile, AO/OTA
• Stability
Young & Burgess
• Mechanism of injury
YOUNG & BURGESS
• Anterior-Posterior Compression (APC)
• Lateral Compression (LC)
• Vertical Shear
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APC
• Diastasis anteriorly through
symphysis pubis (or vertical rami
fractures)
• SI joint diastasis – amount of
displacement defines subset
Images from Rockwood and Green 6th Edition
APC-1
Rockwood and Green 6th Edition
< 2.0 cm diastasis
APC-2
Rockwood and Green 6th Edition
Disruption sacrospinous,
sacrotuberous and anterior SI joint
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APC-3
Rockwood and Green 6th Edition
APC 2 + posterior SI joint
LATERAL COMPRESSION
I: Anterior sacral compression
II: Posterior sacroiliac fracture
dislocation (crescent fracture)
III: Associated contralateral SI
joint/ external rotation injury
Images from Rockwood and Green 6th Edition
LC-3
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VERTICAL SHEAR INJURY
• Cephalad migration
• Unstable
Image from Rockwood and Green 6th Edition
SYMPHYSEAL INJURIES
• APC 1-3
• LC 3
• VS
EVALUATION
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1/9/2014
EVALUATION
• Pelvic fracture marker for high energy
• ATLS guidelines
• Significant morbidity and mortality
–
–
–
–
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Chest - 63%
Long bone fractures - 50%
Head and abdominal injury - 40%
Spine - 25%
GU injuries 12-20%
Increased mortality
•
•
•
•
Age > 60
SBP < 90
Increased ISS
trxn > 4 units
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1/9/2014
EVALUATION
• Hemodynamic stability
– Tachycardia
– Hypotension (SBP 90 = 2L EBL)
– Base deficit
….. Coagulopathy/ hypothermia/ acidosis
• Pelvic stability
– Clinical exam
– Radiographic exam
PHYSICAL EXAM
• Skin
– Open wounds
• vaginal and rectal exam
– Morel Lavalle lesion
PHYSICAL EXAM
• Detailed neurologic exam
– Sensation
– Motor
– Reflexes
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1/9/2014
PHYSICAL EXAM
• GU injury
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–
–
–
–
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Hematuria
Scrotal swelling
Blood at meatus
Displaced prostate
Inability to pass foley
Vaginal tear
• RUG is diagnostic
PHYSICAL EXAM
• GI injury
– Rectal tear/ perineal wounds
– Often need diverting colostomy
PHYSICAL EXAM
PELVIC STABILITY
• Rotational deformity
• Leg length discrepancy
• Compression
• Push/pull
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1/9/2014
IMAGING
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•
•
•
AP pelvis
Inlet view
Outlet view
CT scan
AP PELVIS
• Part of initial ATLS evaluation
• Provides majority of information
• Look for asymmetry, rotation, or
displacement of hemipelvis
• Any anterior ring injury warrants
further imaging
AP PELVIS
• Beware of single measurement of of
symphysis to determine stability
– ? 2.5 cm
– Dynamic stress radiographs give more
complete information
• Beware of images obtained in binder
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1/9/2014
DYNAMIC STRESS VIEWS
• 68 patients EUA
• 37 APC and 31 LC fractures
• 14 “APC 1” -> 50% reclassified as APC2
– 3/7 also required posterior fixation
• 23 “APC2” -> 57% anterior only, 39%
anterior and posterior
• 20 “LC1” -> reclassified as unstable and
required surgery
Sagi et al JOT 2011
DYNAMIC STRESS VIEWS
• Recommend reclassification
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–
–
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APC 2a: anterior fixation
APC2b: anterior and posterior fixation
LC1a: stable, nonop
LC1b internal fixation
Sagi et al JOT 2011
DYNAMIC STRESS VIEWS
• 22 EUA presumed APC1
• 6/22 (27%) diastasis > 2.5 cm with stress
Suzuki et al J Trauma 2010
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1/9/2014
INLET VIEW
• Beam angled 45° caudad
• Ideal image when S1 overlaps S2 body
• Actual angle may be 25°
Ricci et al JBJS 2010
INLET VIEW
• Anterior/posterior displacement
• Rotation of hemipelvis
• SI joint widening
• Sacral ala impaction
Rockwood and Green 6th Edition
OUTLET VIEW
• Xray beam angled 45° cephalad
• Adequate image when superior ramus at
S2 foramen
• Actual angle may be 60°
Ricci et al JBJS 2010
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1/9/2014
OUTLET VIEW
• Cephalad/caudad displacement
• Sacral foramina
Rockwood and Green 6th Edition
CT SCAN
• More detailed assessment posterior injury
– Up to 20-30% initially missed
• Assess neural foramina
• Rotation of fragments/ pelvis
• Contrast-enhanced CT may be helpful in determining
which patients might benefit from angiography
INDICATIONS
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1/9/2014
INDICATIONS FOR ORIF
SYMPHYSIS DIASTASIS
– Symphyseal widening ≥ 2 cm
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•
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APC 2 and APC 3, LC3, VS
May not apply to small patients
Does not account for diastasis at time of injury
Remember stress views
– Unusual pain with APC1 may benefit from
single leg stance view
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1/9/2014
SUMMARY:
SYMPHYSEAL INJURIES
Injury Patterns, Evaluation,
Imaging, and Indications
SYMPHYSEAL INJURIE
• Injury Patterns
– Symphyseal injuries in APC 1-3, LC 3 and VS
• Evaluation
– Detailed physical exam
– Hemodynamic stability
• Imaging
– AP, inlet (25°), outlet (60°)
– CT scan
• Indications
– Diastasis > 2 cm, LC 3 and VS
– Beware of dymamic views
THANK YOU
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1/10/2014
SYMPHYSIS PUBIS INJURIES:
TIMING, POSITIONING, AND EXPOSURE
Timothy Achor, MD
University of Texas at Houston
Memorial Hermann Hospital
disclosures
• Depuy Synthes
LEARNING OUTCOMES
• Discuss timing considerations
• Positioning
• Exposure pearls
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1/10/2014
TIMING
• Historically, wait 2-3 days prior to ORIF
– Await clot formation
– +/- ex fix, binder
• Currently, proceed with ORIF once
patient stablized
– Tremendous pain relief, comfort
– No need for 2nd anesthesia
TIMING
• ORIF can safely be performed in first
24 hours after injury
• Can safely be performed in coordination
with other services
• Can frequently be performed as
expeditiously as pelvic external fixator
TIMING OF BINDER?
Photo courtesy of Michael Archdeacon
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1/10/2014
TIMING
• How long can the binder be left?
POSITIONING
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•
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Supine
Flat radiolucent table
Foley catheter
Image intensifier opposite surgeon
– Surgeon preference
– Presence of posterior ring instability
CONSIDER SLIDING BINDER
DISTALLY TO HELP
MAINTAIN REDUCTION
Gardner et al
JOT 2009
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1/10/2014
Gardner et al JOT 2009
“Internal rotation and taping of the lower
extremities for closed pelvic reduction”
EXPOSURE
• 2 SURGICAL APPROACHES:
– PFANNENSTIEL
– VERTICAL MIDLINE
PFANNENSTIEL
• Shave entire abdomen/pelvic region
• Scrub with chlorhexidine brushes
• Drape off entire region with
Benzoin/clear polypropylene drapes
• Wipe down with EtOH
• THEN prep
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1/10/2014
PFANNENSTIEL
• Transverse incision ~ 2 cm above
pubic symphysis
• Dissection carried down to rectus
fascia
– Cauterize superficial epigastric vessels
– Care along lateral aspects of wound
• Spermatic cord/round ligament
PFANNENSTIEL
• Identify linea alba
• Midline split rectus
– *do NOT transversely incise rectus fascia
Master Techniques in Orthopaedic Surgery: Fractures
2nd Edition. Chapter 38. Templeman, Schmidt, Sems
PFANNENSTIEL
• Identify linea alba
• Midline split rectus
– *do NOT transversely incise rectus fascia
Master Techniques in Orthopaedic Surgery: Fractures
2nd Edition. Chapter 38. Templeman, Schmidt, Sems
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1/10/2014
PFANNENSTIEL
• Identify linea alba
• Midline split rectus
– *do NOT transversely incise rectus fascia
Master Techniques in Orthopaedic Surgery: Fractures
2nd Edition. Chapter 38. Templeman, Schmidt, Sems
PFANNENSTIEL
• Identify linea alba
• Midline split rectus
– *do NOT transversely incise rectus fascia
Master Techniques in Orthopaedic Surgery: Fractures
2nd Edition. Chapter 38. Templeman, Schmidt, Sems
PFANNENSTIEL
• Identify linea alba
• Midline split rectus
– *do NOT transversely incise rectus fascia
Master Techniques in Orthopaedic Surgery: Fractures
2nd Edition. Chapter 38. Templeman, Schmidt, Sems
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1/10/2014
PFANNENSTIEL
• Malleable retractor
Surgical Treatment of Orthopaedic Trauma. Stannard, Schmidt, Kregor
PFANNENSTIEL
• Typically, rectus insertion has been
avulsed unilaterally
• Carefully take down portion rectus
– Leave as much intact as possible
PFANNENSTIEL
If abundant scar tissue or unclear linea
alba, use fluoro aid
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1/10/2014
VERTICAL MIDLINE:
caudal extent of ex lap
VERTICAL MIDLINE
VERTICAL MIDLINE:
other considerations
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1/10/2014
Fungal infection under pannus
SUMMARY
• Timing: Sooner than later
• Positioning: Make your life easier
• Exposure: Pfannenstiel skin incision
with vertical rectus split
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1/13/2014
Disclosures
ML Chip Routt Jr MD - University of Texas Health
Memorial Hermann Hospital - Houston, Texas
Pubic Symphysis Disruption:
Reduction & Fixation
M.L. Chip Routt, Jr., M.D.
Professor
UT Health – Memorial Hermann
Educational Goals
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•
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10 Minutes
Reduction
Clamping
Fixation
Plating
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1/13/2014
The Unstable Pelvis – Broken Doors
Reduction - Manipulation
• 2 People - Iliac Push
• Circumferential Wrap
• External Fixator
Clamping
• Open Reduction – Exposure/Access
• Tenaculum - Pointed
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1/13/2014
Clamping
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•
•
•
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•
Pointed – Bone – Tendon
Posterior Rectus Abdominus
Balanced
Unbalanced
Deformity
Access
Access - Open Wounds
• Perineal - Bleeding
• Manual Reduction - Retract
• Clamp
Clamping
1
2
• Rotation – 1
• Flexion/Extension - 2
1
2
2
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3
1/13/2014
Clamping
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Screw Based
Short Screws
Dissection
Clamp - Genitals
Screw Interference
Power
Correction
Sequence
• Symphysis First
• Then Posterior
Sequencing
• Symphysis First
• Then Posterior
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1/13/2014
Sequencing
Sequencing
• Symphysis First
• Then Posterior
Sequencing
4
3
• Symphysis
1
2
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1/13/2014
Plating
• Where
• What
• Details
2H 4.5mm N DCPlate
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Flexible
Instability
1991
“Perfect!”
2H 4.5mm N DCPlate
• Delayed Failure - Multiplanar
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1/13/2014
6-8H 3.5mm Recon Plate
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Malleable
Contoured
Length
Site
Screws
10H 3.5mm Pelvic Recon Plate
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Plate Length - Peripheral
Contouring
Screw Sites
Screw Lengths
Supra-Acetabular Site
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Peripheral Plate
Contouring Flair
Dome
Drilling
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1/13/2014
Quadrilateral Surface Screw
• Preop Plan
• Image
• Quadrilateral
Trans-Symphyseal
• Standard Site Failure
• Inferior Ramus
• Dodge Others
Trans-Symphyseal
• Bilateral
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1/13/2014
Other Fixation
• Avulsion
• Adductor Origin
• Rectus Abdominus Insertion
Ramus
• Ramus Screw Demanding - First
• Plate Screws Dodge
Locking Plates
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Recent
Holes
Direct
Contour
Allergy
Cost
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1/13/2014
Plate Toxicity
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Excessive Fixation
Long Implant
Excursion to Apply
Contouring
Poor Fit
Double Plating
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Dated Technique
No Fluoroscopy
Posterior Ring
Dissection
Power-up Front
Ignore Back
Mechanical Study
Suturing
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•
Pediatric
Adolescents
Female
Ridge
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1/13/2014
Summary – SP: Reduction & Fixation
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•
Acute
Anterior
Exposure
Clamping
Malleable
Contouring
Plating
Screws
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1/6/2014
Michael J. Gardner, MD
Washington University School of Medicine
St. Louis, MO USA
Pubic Symphysis
• Challenges:
– Difficult to assess all concurrent
injuries which contribute to stability
• Acute fixation failure
–Physiologically mobile articulation
• Late fixation failure
– Implant positioning/ assessment
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1/6/2014
Assessing full extent of injury?
APC-2
Anterior SI Joint,
SS/ST Ligaments
?
APC-3
Posterior SI Ligaments
No cephalad translation
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1/6/2014
Acute Fixation Failure
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•
•
•
92 patients with symphyseal disruption
51 with two-hole plate: 33% failure
41 multi-hole plate:
12% failure
Pooled data: APC-2  22% failure
– Most without posterior fixation
Sagi & Papp, JOT 2008
Acute Fixation Failure
• 44 patients with APC-2 injuries
• Treated with anterior plating and ISS
• 2/44 (4.5% acute fixation failure)
Alton, Merritt, Routt, Gardner, Krieg. In Press
Late Fixation “Failure”
• 127 patients with symphyseal
plating
• 56% had posterior fixation
• Overall, 74% had loosening at
final f/u
• One patient required revision
Collinge et al, CORR 2012
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1/6/2014
Late Fixation “Failure”
• 148 patients with
symphyseal plating
• 63 patients (43%)
hardware breakage
• 5 patients (3%) required
revision
• “Clinically unimportant”,
but no functional
outcomes
Morris et al, CORR 2012
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1/6/2014
• 4.5 months
• Minimally
symptomatic
• Back to work
Implant placement
• 18 F
• Rollover MVC
• Physiologically
stable
6 months
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1/6/2014
Implant placement
“Hyperinlet” view
• Superimpose
superior and
inferior rami and
check screws
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1/6/2014
Locking plates?
• 45M
• MCA
• Isolated
injury
• Stable
patient
Locking plates?
• Post-op
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1/6/2014
Locking plates?
• 1 week
Locking plates?
Don’t need ‘em
Don’t want ‘em
Summary
• Don’t underestimate pelvic instability
– Scrutinize CT; flexion-extension on X-ray
– Liberal use of ISS to “support” symphyseal
plate
• Expect late fixation failures
– Assess for reduction loss/instability
– Listen to patient complaints
• Meticulous screw length/position
assessment
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1/6/2014
Thank you
9