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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 • • • • • 52yo Male MCA Pelvic Pain Complete SI Complete SPubis • • • • Anatomy – Injury Initial Treatment Definitve Treatment Potential Problems Patient Example 1 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 1 1/9/2014 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 2 1/9/2014 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 3 1/9/2014 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 4 1/9/2014 VERTICAL SHEAR INJURY • Cephalad migration • Unstable Image from Rockwood and Green 6th Edition SYMPHYSEAL INJURIES • APC 1-3 • LC 3 • VS EVALUATION 5 1/9/2014 EVALUATION • Pelvic fracture marker for high energy • ATLS guidelines • Significant morbidity and mortality – – – – – 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 6 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 7 1/9/2014 PHYSICAL EXAM • GU injury – – – – – – 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 8 1/9/2014 IMAGING • • • • 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 9 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 – – – – 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 10 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 11 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 12 1/9/2014 INDICATIONS FOR ORIF SYMPHYSIS DIASTASIS – Symphyseal widening ≥ 2 cm • • • • 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 13 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 14 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 1 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 2 1/10/2014 TIMING • How long can the binder be left? POSITIONING • • • • 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 3 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 4 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 5 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 6 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 7 1/10/2014 VERTICAL MIDLINE: caudal extent of ex lap VERTICAL MIDLINE VERTICAL MIDLINE: other considerations 8 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 9 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 • • • • • 10 Minutes Reduction Clamping Fixation Plating 1 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 2 1/13/2014 Clamping • • • • • • 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 1 3 1/13/2014 Clamping • • • • • • • Screw Based Short Screws Dissection Clamp - Genitals Screw Interference Power Correction Sequence • Symphysis First • Then Posterior Sequencing • Symphysis First • Then Posterior 4 1/13/2014 Sequencing Sequencing • Symphysis First • Then Posterior Sequencing 4 3 • Symphysis 1 2 5 1/13/2014 Plating • Where • What • Details 2H 4.5mm N DCPlate • • • • Flexible Instability 1991 “Perfect!” 2H 4.5mm N DCPlate • Delayed Failure - Multiplanar 6 1/13/2014 6-8H 3.5mm Recon Plate • • • • • Malleable Contoured Length Site Screws 10H 3.5mm Pelvic Recon Plate • • • • Plate Length - Peripheral Contouring Screw Sites Screw Lengths Supra-Acetabular Site • • • • Peripheral Plate Contouring Flair Dome Drilling 7 1/13/2014 Quadrilateral Surface Screw • Preop Plan • Image • Quadrilateral Trans-Symphyseal • Standard Site Failure • Inferior Ramus • Dodge Others Trans-Symphyseal • Bilateral 8 1/13/2014 Other Fixation • Avulsion • Adductor Origin • Rectus Abdominus Insertion Ramus • Ramus Screw Demanding - First • Plate Screws Dodge Locking Plates • • • • • • Recent Holes Direct Contour Allergy Cost 9 1/13/2014 Plate Toxicity • • • • • Excessive Fixation Long Implant Excursion to Apply Contouring Poor Fit Double Plating • • • • • • • Dated Technique No Fluoroscopy Posterior Ring Dissection Power-up Front Ignore Back Mechanical Study Suturing • • • • Pediatric Adolescents Female Ridge 10 1/13/2014 Summary – SP: Reduction & Fixation • • • • • • • • Acute Anterior Exposure Clamping Malleable Contouring Plating Screws 11 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 1 1/6/2014 Assessing full extent of injury? APC-2 Anterior SI Joint, SS/ST Ligaments ? APC-3 Posterior SI Ligaments No cephalad translation 2 1/6/2014 Acute Fixation Failure • • • • 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 3 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 4 1/6/2014 • 4.5 months • Minimally symptomatic • Back to work Implant placement • 18 F • Rollover MVC • Physiologically stable 6 months 5 1/6/2014 Implant placement “Hyperinlet” view • Superimpose superior and inferior rami and check screws 6 1/6/2014 Locking plates? • 45M • MCA • Isolated injury • Stable patient Locking plates? • Post-op 7 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 8 1/6/2014 Thank you 9