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

Procedure for Pelvis Diastasis Managed by Plating

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

Indications for Plating

• Rotationally unstable pelvic ring disruptions (APC-II, LC-II)
• Vertically unstable pelvic ring disruptions (APC-III, LC-III, VS, CM)
• Pubic symphysis diastasis >2.5 cm (particularly in "open book" injuries)

Pre-operative Considerations

1. Patient Assessment:

   • Ensure hemodynamic stability before definitive fixation
   • Assess for other injuries requiring treatment
   • Review CT scan to evaluate fracture pattern and displacement

2. Timing of Surgery:

   • Hemodynamically stable patients can undergo early definitive fixation within 24 hours 1
   • Unstable or coagulopathic patients should be resuscitated first 1
   • In polytrauma patients with physiologic derangement, definitive fixation should be postponed until after day 4 post-injury 1

Surgical Procedure

Step 1: Patient Positioning and Preparation

• Position patient supine on a radiolucent table
• Prepare and drape the anterior pelvis with wide exposure
• Place a folded sheet under the sacrum for slight elevation of the pelvis

Step 2: Surgical Approach

• Make a Pfannenstiel incision 2 cm above the pubic symphysis, extending laterally about 8-10 cm
• Incise the fascia in line with the skin incision
• Identify and protect the spermatic cords in males or round ligaments in females
• Retract the rectus abdominis muscles superiorly to expose the pubic symphysis
• Take care to maintain adequate intactness of rectus sheath to avoid long-term complications 2

Step 3: Reduction of Diastasis

• Remove hematoma and debris from the symphyseal space
• Use pointed reduction forceps to reduce the diastasis
• Ensure anatomic reduction of the pubic symphysis under direct visualization
• Confirm reduction with intraoperative fluoroscopy

Step 4: Plate Application and Fixation

• Select an appropriate plate (typically a 6-hole 3.5mm symphyseal plate)
• Position the plate on the superior aspect of the pubic symphysis
• Options for plate placement:
  • Single anterior/superior plate (standard technique)
  • Double perpendicular plates (for additional stability in severe cases) 2

Step 5: Screw Insertion

• Drill pilot holes through the plate into the pubic rami
• Insert bicortical screws (typically 3.5mm)
• Option to use locking plates/screws, though biomechanical studies show no significant advantage over standard plating in osteopenic bone 3
• Ensure screws have adequate purchase in bone
• Typical configuration: 3 screws on each side of the symphysis

Step 6: Posterior Fixation (if indicated)

• For APC-III injuries or other vertically unstable patterns, posterior fixation is required 2
• Options include:
  • Percutaneous iliosacral screws
  • Posterior plating
  • Spinopelvic fixation for vertically unstable sacral fractures 1

Step 7: Wound Closure

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

Post-operative Management

1. Immediate Post-operative Care:

   • Prophylactic antibiotics for 24 hours
   • DVT prophylaxis
   • Pain management

2. Mobilization:

   • Early mobilization is encouraged
   • Weight-bearing status depends on injury pattern:
     • Rotationally unstable injuries: Protected weight-bearing with crutches
     • Vertically unstable injuries with posterior fixation: Limited weight-bearing for 8-12 weeks

3. Follow-up:

   • Clinical and radiographic assessment at 2 weeks, 6 weeks, 3 months, and 6 months
   • Monitor for implant failure, which can occur in up to 75% of cases but may not require revision 4

Potential Complications

• Implant failure (screw loosening or plate breakage) in up to 75% of cases 4
• Recurrent symphyseal widening (average 3.5mm increase from immediate post-op) 4
• Infection (superficial or deep)
• Deep venous thrombosis
• Bladder herniation or screw migration into bladder 5
• Revision surgery (required in approximately 1-6% of cases despite radiographic failure) 4

Special Considerations

• For open pelvic fractures, prioritize bleeding control and management of perineal contamination before definitive fixation 1
• In elderly patients, consider early angiography/angioembolization regardless of hemodynamic status 1
• In cases with significant bleeding, temporary external fixation may be applied before definitive internal fixation 1