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Anterior Pelvic Injuries

- Discussion:
    - anterior injury may be through symphysis or thru pubic rami unilaterally or bilaterally;
          - symphysis disruption may also occur with pubic rami fractures;
    - posterior injury: degree of SI joint disruption depends on the energy sustained during the trauma;
          - sacrotuberous and sacrospinous ligaments may be disrupted;
          - when posterior SI ligaments are disrupted the open book injury is considered unstable;
    - Classification of AP Pelvic Fractures:
          - diastasis > 1 cm represents pubic instability;
                - however, in female patients that have had children, this may be a normal width;
          - diastasis of > 2.5 cm represents ligamentous damage at SI joint;
          - references:
                - Does 2.5 cm of symphyseal widening differentiate anteroposterior compression I from anteroposterior compression II pelvic ring injuries?
                - Stress radiograph to detect true extent of symphyseal disruption in presumed anteroposterior compression type I pelvic injuries.
          - impotence:
                - occurs in 37 % of diastasis patients as result of injury of nervi erigentes or interruption of
                         the penile blood supply;
bladder or urethra injury:
                - may occur in 50% pts w/ a straddle frx;
          - posterior injury:
                - posterior lesion may be frx of ilium, sacral frx, or SI dislocation, usually w/ portion of ilium
                         remaining attached to main sacral frag;
                - do not confuse an "isolated pubic ramus frx" w/ LC-I injury pattern;

- Work Up:  Physical Exam and Radiographs (reduction of pelvic volume)

- Non Operative Treatment:
    - generally pubic rami fractures do not require surgical treatment;
    - should be considered for anterior diastasis of less than 2.5 cm;
    - example:
          - this patient sustained a 2.3 cm diastasis following a parachute injury;
          - one week after injury the diastasis closed down to 1.6 cm and did well with non operative treatment;


- Indications for Plating:
    - open book fracture, more than 2.5 cm;
    - ORIF may also be indicated when there has been concomitant genitourinary injuries;
           - ref: Internal Fixation in Pelvic Fractures and Primary Repairs of Associated Genitourinary Disruptions: A Team Approach
    - avoid operating on patients who have previously been operated on for abdominal or urologic injuries;
           - fascial planes may be disrupted placing the bladder and other visceral structures at risk
                   during symphsis pubis repair;
           - in these cases consider external fixation;

- PreOp Planning:
    - need to determine the amount of posterior instability;
           - ref: Posterior Fixation of APC-2 Injuries Decreases Rates of Anterior Plate Failure and Malunion
    - vertical shear injury
           - these frx are unstable and while acceptable reduction of posterior displacement may be
                  obtained by anterior plating, recurrent displacement posteriorly typically occurs;
                  - posterior or verticle displacement may occur despite application of traction or an external fixator;
                  - some authors recommend double plating inorder to provide additional stability;
           - hence posterior stabilization is required following anterior plating;
    - concomitnat repair of pelvic frx and GU injuries:
           - pt is positioned supine on a flouro table;
           - ref: Internal Fixation in Pelvic Fractures and Primary Repairs of Associated Genitourinary Disruptions: A Team Approach

- Anterior Fixation Methods:
    - anterior fixation alone is indicated for type II fractures, where as type III require anterior fixation
            along with posterior fixation;
            - ref: Current Trends in the Surgical Treatment of Open-Book Pelvic Ring Injuries: An International Survey Among Experienced Trauma Surgeons.
    - treatment options:
            - Orthomed pelvic reduction clamps (temporary for reduction of pelvic volume)
            - External Fixation:
                      - indicated for SI diastasis or pubic ramus frx which cannot be treated by open reduction
                                or screw fixation;
                      - such as may occur w/ suprapubic cystostomy tube or open frx;
            - Open Reduction and Plate Fixation:
                      - types of anterior plates:
                      - indicated for pubic diastasis greater than 2.5 cm;
            - Retrograde Medullary Superior Ramus Screw:
                      - indicated for superior ramus fractures which occur along w/ an ustable posterior injury

Pelvic ring disruptions with symphysis pubis diastasis. Indications, technique, and limitations of anterior internal fixation.

Stress fractures of the pubic ramus. A report of twelve cases.

The Symphysis Pubis: Anatomic and Pathologic Considerations

Impotence after fractures of the pelvis

Internal fixation of symphyseal disruption resulting from childbirth

Open reduction and internal fixation of a traumatic diastasis of the pubic symphysis: one-year radiological and functional outcomes

Complications of Anterior Subcutaneous Internal Fixation for Unstable Pelvis Fractures: A Multicenter Study

Management outcomes in pubic diastasis: our experience with 19 patients.

The long-term clinical outcome after pelvic ring injuries

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