Orthopedics

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Case Reports 

External Fixation of Pubic Symphysis Diastasis from Postpartum Trauma

Jonathan L. Chang, MD; Vincent Wu, MS

Abstract

Pubic symphysis diastasis is acknowledged as a possible complication of pregnancy. The incidence of postpartum pubic symphysis diastasis ranges from 1 of 521 to 1 to 30,000 vaginal deliveries.1 Ligament disruption, swelling within in the joint, and hemorrhage are symptoms of symphysis pain that suggest pubic symphysis diastasis. Relaxin has been discovered as a hormonal contributor of pubic joint laxity during pregnancy.2 Women with high levels of relaxin may experience widening and loss of stiffness in the pubic symphysis and potential instability of this joint. Combined with labor, this instability increases the risk of pubic symphysis diastasis.

This article presents a case of postpartum trauma pubic symphysis diastasis in a patient with pelvic organ damage who was treated with external fixation and recovered from pubic symphysis diastasis with extensive return of function.

A 36-year-old woman of medium build had a successful vaginal delivery of her second average healthy baby. After the delivery, the patient was noted to have a substantial hemorrhage that was unable to be controlled vaginally. The patient underwent emergency surgery to control the bleeding through a lower abdominal and pelvic incision. Severe hemorrhage continued and the bleeding was not able to be adequately contained, resulting in cardiac arrest.

Due to the excessive bleeding, the pelvis was packed to allow for greater cardiovascular and hemodynamic stability in a future operation. A pelvic radiograph demonstrated a nondisplaced right pubis fracture and a pubic symphysis widening measured at 7.75 cm (Figure 1).

Obstetric findings at this point included a rupture of both the vagina and uterus. Because of the patient’s pubic ramus fracture and the pending obstetrical surgery, emergency pelvic external frame was recommended to hold a reduction of the pelvis. Although external fixation is mechanically inferior to internal fixation, the fact that the vaginal field and its proximity were contaminated from the ruptured viscera, prompted the decision to proceed with this treatment.

After stabilization had been obtained in the intensive care unit, the patient was returned to the operating room 2 days after her delivery for closure of the abdomen. An external pelvic fixator frame was applied using 2 fixation pins in each hemipelvis as part of a Synthes system. Reduction of the symphyseal widening was obtained under fluoroscopic guidance, and tightening of the frame was accomplished once adequate reduction was obtained (Figure 2A).

Postoperative radiographs showed good reduction of the pelvis, but a partial loss of reduction occurred and the patient underwent re-manipulation and reduction 4 days later. Again under fluoroscopic guidance, the frame was re-tightened and to improve rigidity, a second level frame was applied. A distance of 1.5 cm was then able to be obtained and final tightening occurred (Figure 2B).

Postoperatively, the patient’s rehabilitation protocol involved being assisted with bed-to-chair and chair-to-bed transfers, with all other ambulation restricted for 2 weeks. As her general health improved, she was allowed weight bearing as tolerated. She began full weight bearing 4 weeks after placement of the fixator, once her medical condition had stabilized sufficiently to allow it. Two months after placement of the initial frame, the frame was removed (Figure 3).

Postoperative care was unremarkable, and the patient was able to successfully gradually increase her walking endurance in a pain-free gait. Multiple postoperative radiographs demonstrated maintenance of reduction of the pelvis, with some fluctuation of pubic symphyseal distance, likely based on imaging technique. One minor postoperative problem occurred in that persistent left calf pain was present as the patient increased her walking endurance, and due to concern for possible deep venous thrombosis, a Doppler study was performed and was found to be negative.

At 18-month follow-up, the…

Pubic symphysis diastasis is acknowledged as a possible complication of pregnancy. The incidence of postpartum pubic symphysis diastasis ranges from 1 of 521 to 1 to 30,000 vaginal deliveries.1 Ligament disruption, swelling within in the joint, and hemorrhage are symptoms of symphysis pain that suggest pubic symphysis diastasis. Relaxin has been discovered as a hormonal contributor of pubic joint laxity during pregnancy.2 Women with high levels of relaxin may experience widening and loss of stiffness in the pubic symphysis and potential instability of this joint. Combined with labor, this instability increases the risk of pubic symphysis diastasis.

This article presents a case of postpartum trauma pubic symphysis diastasis in a patient with pelvic organ damage who was treated with external fixation and recovered from pubic symphysis diastasis with extensive return of function.

Case Report

A 36-year-old woman of medium build had a successful vaginal delivery of her second average healthy baby. After the delivery, the patient was noted to have a substantial hemorrhage that was unable to be controlled vaginally. The patient underwent emergency surgery to control the bleeding through a lower abdominal and pelvic incision. Severe hemorrhage continued and the bleeding was not able to be adequately contained, resulting in cardiac arrest.

 
Figure 1: Pubic symphysis diastasis of 7.75 cm wide after vaginal delivery
Figure 1: Pubic symphysis diastasis of 7.75 cm wide after vaginal delivery.

Due to the excessive bleeding, the pelvis was packed to allow for greater cardiovascular and hemodynamic stability in a future operation. A pelvic radiograph demonstrated a nondisplaced right pubis fracture and a pubic symphysis widening measured at 7.75 cm (Figure 1).

Obstetric findings at this point included a rupture of both the vagina and uterus. Because of the patient’s pubic ramus fracture and the pending obstetrical surgery, emergency pelvic external frame was recommended to hold a reduction of the pelvis. Although external fixation is mechanically inferior to internal fixation, the fact that the vaginal field and its proximity were contaminated from the ruptured viscera, prompted the decision to proceed with this treatment.

After stabilization had been obtained in the intensive care unit, the patient was returned to the operating room 2 days after her delivery for closure of the abdomen. An external pelvic fixator frame was applied using 2 fixation pins in each hemipelvis as part of a Synthes system. Reduction of the symphyseal widening was obtained under fluoroscopic guidance, and tightening of the frame was accomplished once adequate reduction was obtained (Figure 2A).

Postoperative radiographs showed good reduction of the pelvis, but a partial loss of reduction occurred and the patient underwent re-manipulation and reduction 4 days later. Again under fluoroscopic guidance, the frame was re-tightened and to improve rigidity, a second level frame was applied. A distance of 1.5 cm was then able to be obtained and final tightening occurred (Figure 2B).

Figure 2A: External fixation of pubic symphysis diastasis after operative reduction
Figure 2B: Reinforced external fixation to maintain reduction four days after initial reduction
Figure 3: Pubic symphyseal distance maintained at 1.5 cm on removal of external fixation
Figure 2: External fixation of pubic symphysis diastasis after operative reduction (A). Reinforced external fixation to maintain reduction four days after initial reduction (B). Figure 3: Pubic symphyseal distance maintained at 1.5 cm on removal of external fixation.

Postoperatively, the patient’s rehabilitation protocol involved being assisted with bed-to-chair and chair-to-bed transfers, with all other ambulation restricted for 2 weeks. As her general health improved, she was allowed weight bearing as tolerated. She began full weight bearing 4 weeks after placement of the fixator, once her medical condition had stabilized sufficiently to allow it. Two months after placement of the initial frame, the frame was removed (Figure 3).

Postoperative care was unremarkable, and the patient was able to successfully gradually increase her walking endurance in a pain-free gait. Multiple postoperative radiographs demonstrated maintenance of reduction of the pelvis, with some fluctuation of pubic symphyseal distance, likely based on imaging technique. One minor postoperative problem occurred in that persistent left calf pain was present as the patient increased her walking endurance, and due to concern for possible deep venous thrombosis, a Doppler study was performed and was found to be negative.

Figure 4: Pubic symphysis distance of 1.7 cm 18 months after pelvic external frame removal
Figure 4: Pubic symphysis distance of 1.7 cm 18 months after pelvic external frame removal.

At 18-month follow-up, the patient demonstrated a normal heel-toe gait without pain and with ambulatory endurance up to one mile. Radiographs showed a final 1.7-cm gap in the pubic symphysis (Figure 4). The patient reported complete restoration of function and full range of activities of daily living.

Discussion

Historically, pubic symphysis diastasis is conservatively treated with a pelvic girdle and rest with some success. However, conservative treatment may not treat all patients with pubic symphysis diastasis sufficiently. Unstable pubic symphysis diastasis, or diastasis >40 mm, may require surgical intervention to preserve the integrity of the pubic symphysis joint.3

Surgical fixation of the pelvic ring has been studied and described to have stabilized pubic symphysis diastasis successfully.4,5 Most surgical procedures for reduction of pubic symphysis diastasis have been via internal fixation with plates and screws on superior pubic rami bilaterally, and have shown significant success from this problem.6,7 External fixation has been studied on pubic symphysis diastasis patients caused by high-velocity trauma but not from postpartum trauma.8 A search of the literature has not shown use of pelvic external fixation frames for postpartum trauma pubic symphysis diastasis patients until 1996, when a case of successfully used external fixation on a patient with postpartum pubic symphysis diastasis with potentially infected site was published.9

Pubic symphysis diastasis and open book injuries of the pelvis are typically associated with high energy trauma to the pelvis due to either direct force on the ischial tuberosities or indirect loading through the hip joints. Injuries such as a motorcyclist hitting a saddle during sudden change of velocity can cause significant separation of pubic joint.10 High energy traumas usually cause sudden distortions of the pelvic anatomy often associated with blunt injuries of the pelvic ring, such as sacro-iliac joint separation in addition to pubic symphysis diastasis.11

Although postpartum pubic symphysis diastasis may have the similar end result as high energy trauma pubic symphysis diastasis, there are many etiological differences between these two injuries. The pubic ligament laxity during pregnancy in conjunction with hard, precipitous labor; cephalopelvic disproportion; multiparity; trauma caused by forced abduction of the maternal thigh during delivery; or an abnormal presentation of the infant may result in pubic symphysis diastasis that is different from high velocity trauma pubic symphysis diastasis. Radiographic study suggests pubic symphysis diastasis following vaginal delivery resembles an anterior compression pelvic injury.12 However, the difference is that postpartum pubic symphysis diastasis is a result of force applied from a point posterior to the pubic symphysis. This is in contrast to the high energy trauma pubic symphysis diastasis in which the force is applied a point anterior to the pubic symphysis.

Other possible surgical management of this patient include anterior cerclage wiring, anterior plating with screws, and external fixation.9 Although internal fixation is represented as a more stable management method from previous studies, this patient was not suitable for internal fixation due to her pubic ramus fracture, vaginal and uterine rupture with site contamination, and massive hemorrhage that caused her to arrest after delivery. Because a contaminated field was encountered in this pelvic diastasis case, internal fixation could compromise her obstetrical surgery with wound infection and osteomyelitis. External fixation would bypass the possible infection and obstetric complications while maintaining the reduction of her pubic symphysis diastasis. The results of this patient showed substantial improvement of her function while greatly reducing her risk of infection.

External fixation provides an excellent alternative pathway to reduce pubic symphysis diastasis compared with internal fixation. External fixation is highly recommended for pubic symphysis diastasis patients who also suffer significant pelvic organ damage and/or hemorrhage.

References

  1. Lindsey RW, Leggun, Wright DG, Nolasco UR. Separation of the symphysis pubis in association with childbearing. A case report. J Bone Joint Surg Am. 1988; 70(2):289-292.
  2. Goldsmith LT, Weiss G, Stienetz BG. Relaxin and its role in pregnancy. Endocrinol Metab Clin North Am. 1995; 24(1):171-186.
  3. Petersen AC, Rasmussen KL. External skeletal fixation as treatment for total puerperal rupture of the pubic symphysis. Acta Obstetricia et Gynecologica Scandinavica. 1992; 71(4):308-310.
  4. Tile M. Pelvic ring fractures: should they be fixed? J Bone Joint Surg Br. 1988; 70(1):1-12.
  5. Matta J M, Saucedo T. Internal fixation of pelvic ring fractures. Clin Orthop Relat Res. 1989; 242:83-97.
  6. Brodersen M, Pettit P, Chen A, Levia JL, Bofill M. Surgical repair of pubic symphysis diastasis. Journal of Pelvic Medicine and Surgery. 2006; 12(3):157-160.
  7. Mulhall KJ, Khan Y, Ahmed A, O’Farrell D, Burke TE, Moloney M. Diastasis of the pubic symphysis peculiar to horse riders: modern aspects of pelvic pommel injuries. Br J Sports Med. 2002; 36(1); 74-75.
  8. Pennig D. The place of anterior external fixation in the stabilization of pelvic ring disruptions. Int J Orthop Trauma. 1993; 3(suppl):44-48.
  9. Pennig D, Gladbach B, Majchrowski W. Disruption of the pelvic ring during spontaneous childbirth, A case report. J Bone Joint Surg Br. 1997; 79(3):438-440.
  10. Mulhall KJ, Khan Y, Ahmed A, O’Farrell D, Burke TE, Moloney M. Diastasis of the pubic symphysis peculiar to horse riders: modern aspects of pelvic pommel injuries. Br J Sports Med. 2002; 36(1):74-75.
  11. Young JW, Resnik CS. Fracture of the Pelvis: Current Concepts of Classification. AJR Am J Roentgenol. 1990; 155(6):1169-1175.
  12. Kowalk DL, Perdue PS, Bourgeois FJ, Whitehill R. Disruption of the symphysis pubis during vaginal delivery. A case report. J Bone Joint Surg Am. 1996; 78(11):1746-1748.

Authors

Dr Chang and Mr Wu are from the Department of Orthopedics, University of Southern California, Pacific Orthopedic Medical Group, Alhambra, California.

Dr Chang and Mr Wu have no relevant financial relationships to disclose.

Correspondence should be addressed to: Jonathan L. Chang, MD, Department of Orthopedics, University of Southern California, Pacific Orthopedic Medical Group, 707 S Garfield Ave, Alhambra, CA 91801.

10.3928/01477447-20080501-05

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