Surgical Procedure for Pubic Symphysis Diastasis Plating
The definitive treatment of choice for pubic symphysis diastasis >2.5 cm (APC-II, APC-III patterns) is anterior plate fixation through a Pfannenstiel approach. 1
Preoperative Assessment and Planning
Confirm diagnosis and extent of injury with imaging:
Ensure hemodynamic stability before proceeding with definitive fixation 1
- Unstable patients require resuscitation first
- Consider temporary external fixation for significant bleeding before definitive internal fixation
Surgical Procedure Steps
1. Patient Positioning and Preparation
- Position patient supine on a radiolucent table
- Prepare and drape the lower abdomen, pubic region, and proximal thighs
- Ensure C-arm availability for intraoperative fluoroscopy
2. Surgical Approach
- Make a Pfannenstiel incision 2 cm above the pubic symphysis, extending 8-10 cm laterally
- Incise the anterior rectus fascia in line with the skin incision
- Separate the rectus abdominis muscles in the midline
- Identify and protect the spermatic cords in males or round ligaments in females
3. Exposure of Pubic Symphysis
- Elevate the rectus abdominis muscles from the pubic bones
- Clear soft tissue from the anterior aspect of the pubic symphysis
- Identify the diastasis between the pubic bones
- Remove any interposed soft tissue or hematoma from the symphyseal space
4. Reduction Technique
- Use pointed reduction forceps to reduce the diastasis
- Apply manual pressure on the iliac wings to assist reduction
- Confirm anatomic reduction with fluoroscopy
- Temporary fixation with K-wires may be used to maintain reduction
5. Plate Application and Fixation
- Select an appropriate plate:
- Standard 6-8 hole 3.5mm reconstruction plate or
- Specialized symphyseal plate or
- Locking plate system 3
- Position the plate on the superior aspect of the pubic symphysis
- Ensure the plate is centered over the symphysis with equal distribution on both sides
- Drill and place screws in sequence:
- Start with one screw on each side of the symphysis
- Complete with remaining screws (typically 3-4 screws on each side)
- Use locking screws when available for better fixation 3
6. Verification of Fixation
- Confirm adequate reduction and fixation with fluoroscopy
- Ensure no screw penetration into the hip joint
- Test stability of the fixation
7. Wound Closure
- Irrigate the wound thoroughly
- Close the rectus fascia with absorbable sutures
- Close subcutaneous tissue and skin in layers
- Apply sterile dressing
Posterior Fixation Considerations
- For APC-III injuries or other vertically unstable patterns, posterior fixation is required in addition to anterior plating 1
- Options include:
- Percutaneous iliosacral screws
- Posterior plating
- Spinopelvic fixation for vertically unstable sacral fractures
Postoperative Management
- Prophylactic antibiotics for 24 hours
- DVT prophylaxis
- Pain management
- Early mobilization with appropriate weight-bearing restrictions:
- Rotationally unstable injuries: protected weight-bearing with crutches
- Vertically unstable injuries with posterior fixation: limited weight-bearing for 8-12 weeks 1
Potential Complications and Considerations
- High rate of radiographic implant failure (43-75%) but low rate of clinically significant failure requiring revision (3-6%) 4, 5
- Hardware breakage is common but usually asymptomatic 4
- Recurrent widening of the pubic space can be expected after plating but rarely requires revision 5
- Consider dual plate fixation or trans-symphyseal cross-screws for better biomechanical stability in high-risk cases 6
Special Considerations
- For open pelvic fractures, prioritize bleeding control and management of perineal contamination before definitive fixation 1
- In polytrauma patients with physiologic derangement, definitive fixation should be postponed until after day 4 post-injury 1
- External fixation may be considered as an alternative in cases with significant reproductive organ damage or contaminated pelvic environment 7