What are the step-by-step operative notes for the treatment of a fracture of the superior pubic ramus with diastasis using open reduction and internal fixation (ORIF) with plating?

From the Guidelines

The operative notes for a superior pubic ramus fracture with diastasis treated by plating should begin with patient positioning in the supine position on a radiolucent table after administration of general anesthesia and appropriate prophylactic antibiotics, as this approach has been shown to be effective in achieving anatomic reduction and stable fixation [ 1 ]. The goal of this procedure is to stabilize the pelvic ring, allowing for early mobilization while the fracture heals, which typically takes 8-12 weeks for adequate bony union.

Key Steps:

• Patient positioning in the supine position on a radiolucent table
• Administration of general anesthesia and appropriate prophylactic antibiotics
• A Pfannenstiel incision is made approximately 2 cm above the pubic symphysis
• The rectus abdominis muscles are identified and separated at the midline, with careful retraction to expose the pubic symphysis and superior rami
• The fracture site and diastasis are identified and debrided of hematoma and soft tissue
• Reduction of the fracture and diastasis is performed using reduction clamps to restore anatomical alignment, confirmed with fluoroscopy
• A pre-contoured pubic symphysis plate (typically a 3.5mm reconstruction plate) is selected and positioned across the symphysis and extending to the superior rami
• The plate is temporarily secured with K-wires, and proper positioning is confirmed with fluoroscopy
• Screws are then placed sequentially, typically starting centrally and working laterally, with screw lengths determined by depth measurement
• After all screws are placed, final fluoroscopic images are obtained to confirm adequate reduction and hardware position
• The wound is irrigated thoroughly, and hemostasis is achieved
• The rectus muscles are reapproximated with absorbable sutures, followed by fascial closure, subcutaneous tissue closure, and skin closure
• A sterile dressing is applied

Important Considerations:

• Pubic symphysis plating represents the modality of choice for anterior fixation of “open book” injuries with a pubic symphysis diastasis > 2.5 cm [ 1 ]
• The technical modality of posterior pelvic ring fixation remains a topic of debate, and individual decision-making is largely guided by surgeons’ preference [ 1 ]
• Patients hemodynamically stable and mechanically unstable with no other lesions requiring treatment and with a negative CT-scan can proceed directly to definitive mechanical stabilization [ 1 ]

From the Research

Operative Notes for ORIF with Plating

The step-by-step operative notes for the treatment of a fracture of the superior pubic ramus with diastasis using open reduction and internal fixation (ORIF) with plating are as follows:

• Preoperative preparation:
  • Patient positioning: supine position on a radiolucent table
  • Imaging: intraoperative fluoroscopy to confirm reduction and hardware placement
• Approach:
  • Pfannenstiel incision or a midline incision to access the pubic symphysis and superior pubic ramus
  • Dissection and exposure of the fracture site
• Reduction:
  • Manual reduction of the fracture fragments
  • Use of reduction clamps or instruments to maintain reduction
• Fixation:
  • Placement of a 3.5-mm or 4.5-mm reconstruction plate along the superior pubic ramus
  • Securing the plate with 3.5-mm or 4.5-mm cortical screws
  • Ensuring proper plate contouring and screw placement to avoid hardware failure 2, 3
• Closure:
  • Closure of the incision in layers
  • Application of a dressing and immobilization as needed

Considerations and Complications

• Bone quality: poor bone quality, such as in osteoporotic patients, may affect the stability of the fixation 3
• Implant failure: implant failure can occur due to screw cutting through the cancellous bone or plate bending 3
• Loss of reduction: loss of reduction can occur due to various factors, including patient age, fracture location, and screw placement technique 4
• Neurologic, vascular, or urologic injury: these complications can occur due to the proximity of the fracture site to vital structures 4

Alternative Fixation Methods

• Retrograde medullary screw fixation: this method involves placing a screw through the medullary canal of the superior pubic ramus 2
• Percutaneous screw fixation: this method involves placing screws through small incisions to stabilize the fracture 4
• External fixation: this method involves using an external fixator to stabilize the pubic symphysis and superior pubic ramus 5