Pubic symphysis plating

  • Indication

  • Anatomy

  • Considerations

  • Positioning

  • Skin incision

  • Superficial dissection

  • Deep dissection

  • Exposure extension

  • Closure

  • Post operatively

  • References

    •

    Indication

    See pelvic fractures consider anterior and posterior pelvic injury.

    Symphyseal disruption greater than 2.5 cm.

    If laparotomy and faecal contamination consider external fixation.

    Suprapubic bladder catheter increases risk of infection consider external fixation

     

    Anatomy

    Catheterise Viz bladder

     

    Considerations

     

    Positioning

    Supine

    Radiolucent table to enable inlet and outlet views screening at end of procedure.

     

    Skin Incision

    Pfannanstiel incision, 2cm, 1 finger breadth above pubic symphysis, (not directly over bone).

    If following laparotomy or bladder repair, may be midline incision.

     

    Superficial dissection

    Dissect down to deep fascia, identify midline. Usually the attachment of one of the recti is avulsed.

     

    Deep dissection

    Elevate rectus abdominus of pubic rami. Two ways to do it:

    1. Vertical midline incision through linea alba. Cut down onto pubic rami through periosteum behind rectus (use spiked Homans under rectus to aid exposure) do subperiosteal dissection elevating the back of rectus off pubic body and rami. Expose pubic symphysis, body and enough of superior pubic rami to allow plating.

    2. Transverse incision through aponeurotic insertion of rectus abdominus (leave small cuff for reattachment), allows for more extensive exposure. (protect inferior epigastric artery and spermatic cord)

    Carefully dissect behind body of pubis avoiding injury to bladder or prostatic venous plexus.

    Place finger behind pubis to ascertain angle for drill and screws.

    Avoid placing screws into pubic symphysis.

     

    Stable injury (consider posterior ring injury)

    • Superior plate, contour, (sharper angle in males)

    • 3.5 or 4.5mm reconstruction plate (depends on size of patient), 2 hole or 4 hole plate. (use 7 hole 4.5 mm plate and contour with middle hole over pubic symphysis, 6.5 mm fully threaded cancellous screws)

    • Fully threaded cancellous screws

    Unstable pelvic injury (consider posterior ring injury)

    • Consider double plating (superior and anterior) as above. At least 2 hole superiorly, 4 hole anteriorly.

    Reduction (several ways)

    • Attach plate to one side and reduce other side onto it.

    • Use pointed reduction clamps directly onto bone or into 2 drill holes.

    Exposure extension

    Muscle paralysis helps

    For bigger exposure consider releasing rectus abdominus with transverse incision (see above)

     

    Closure

    Close in layers.

    If rectus detached repair carefully (muscle paralysis helps, so does flexing the table)

     

    Post operatively

    Check radiographs (consider intra operative screening post fixation)

    • Pelvic inlet and outlet views best

    • Check screw lengths, ensure no screws entering pubic symphysis

    In stable pelvic injury (posterior injury) mobilize once comfortable full weight bearing on uninvolved side.

    In women of childbearing age consider removal (no sooner than 1 year after injury)

     

    References

    Fractures of the pelvis and acetabulum 2nd edition; Tile M

     

    Personal observations

    Page created by: Lee Van Rensburg
    Last updated 11/09/2015