What is the step-by-step procedure for treating pelvis diastasis using plating?

Step-by-Step Procedure for Pelvis Diastasis by Plating

Pubic symphysis plating is the treatment of choice for anterior fixation of "open book" injuries with a pubic symphysis diastasis > 2.5 cm (APC-II, APC-III) 1.

Pre-Operative Assessment and Planning

1. Determine fracture pattern and stability:

   • Identify the type of pelvic ring injury using Young & Burgess classification
   • Confirm pubic symphysis diastasis > 2.5 cm requiring surgical fixation
   • Assess for associated posterior ring injuries that may require additional fixation

2. Timing of surgery:

   • Hemodynamically unstable patients should be resuscitated before definitive fixation 1
   • Hemodynamically stable patients can undergo early fixation within 24 hours 1
   • Physiologically deranged polytrauma patients should have fixation postponed until after day 4 1

Surgical Procedure for Pubic Symphysis Plating

Step 1: Patient Positioning and Preparation

• Position patient supine on a radiolucent table
• Prepare and drape the anterior pelvis with sterile technique
• Ensure C-arm availability for intraoperative fluoroscopy

Step 2: Surgical Approach

• Make a Pfannenstiel incision approximately 2 cm above the pubic symphysis
• Incise the fascia in the midline and identify the rectus abdominis muscles
• Carefully separate the rectus muscles in the midline, preserving the rectus sheath integrity to prevent long-term complications 2
• Expose the pubic symphysis and adjacent pubic rami

Step 3: Reduction of Diastasis

• Remove any hematoma or debris from the symphyseal joint
• Use reduction forceps or a pelvic reduction clamp to reduce the diastasis
• Achieve anatomic reduction of the symphysis under direct visualization
• Confirm reduction with fluoroscopy in AP, inlet, and outlet views

Step 4: Plate Application and Fixation

• Select appropriate plate (typically a 4-6 hole 3.5mm reconstruction plate or dedicated symphyseal plate)
• Position the plate on the superior aspect of the pubic symphysis
• For APC-II injuries:
  • Single anterior/superior plate is sufficient 2
  • Alternative: double perpendicularly placed plates for additional stability 2
• For APC-III injuries:
  • Anterior symphyseal plating must be combined with posterior stabilization 1, 2

Step 5: Screw Placement

• Drill pilot holes through the plate into the pubic rami
• Measure appropriate screw length
• Insert 3.5mm cortical screws bicortically
• Typically use 3 screws on each side of the symphysis
• Avoid penetrating the hip joint or bladder during drilling and screw placement

Step 6: Verification of Fixation

• Confirm plate and screw position with fluoroscopy
• Ensure adequate reduction of the diastasis
• Check stability of the fixation

Step 7: Wound Closure

• Irrigate the wound thoroughly
• Close the rectus sheath with strong absorbable sutures
• Close subcutaneous tissue and skin in layers
• Apply sterile dressing

Post-Operative Management

1. Early Mobilization:

   • For isolated anterior ring injuries (APC-II) with stable fixation, mobilization can begin as early as day 1 3
   • For combined injuries (APC-III), weight-bearing restrictions may apply based on posterior fixation

2. Weight-bearing Protocol:

   • Touch-down weight bearing for 6-8 weeks for APC-II injuries
   • Protected weight bearing for 10-12 weeks for APC-III injuries

3. Follow-up Imaging:

   • Radiographs at 2 weeks, 6 weeks, 3 months, and 6 months to assess healing and maintenance of reduction

Special Considerations

1. Biomechanical Considerations:

   • Single superior plating provides the strongest fixation for pubic symphysis diastasis 4
   • Some loss of reduction (1.5-4.0 mm) may occur over time regardless of fixation method 5

2. Associated Injuries:

   • For APC-III injuries with posterior instability, posterior fixation is mandatory 1, 6
   • Options for posterior fixation include iliosacral screws, posterior plating, or spinopelvic fixation 1

3. Time-Critical Management:

   • Time between hospital admission and bleeding control procedures should not exceed 60 minutes 1
   • Mortality increases by 1% for every additional 3 minutes delay in controlling hemorrhage 1

This procedure aims to achieve anatomic reduction and stable fixation of the pubic symphysis diastasis, allowing early functional rehabilitation and decreasing long-term morbidity associated with pelvic ring injuries.