What are the treatment options for excessive symphyseal separation?

Clinical Implications of Excessive Symphyseal Separation

Excessive symphyseal separation (>2.5 cm) requires surgical fixation with pubic symphysis plating to restore pelvic stability and prevent chronic pain, functional disability, and long-term complications. 1

Defining Excessive Separation

Symphyseal diastasis >10 mm is diagnostic of pathologic separation, though the threshold for intervention is higher. 2 Normal physiologic widening during pregnancy and delivery can reach up to 10 mm, but separations exceeding 25 mm (2.5 cm) represent significant structural instability requiring intervention. 1, 3

Immediate Clinical Consequences

Acute Presentation

• Severe suprapubic and/or sacroiliac pain occurring within 24 hours postpartum, often accompanied by an audible "crack" during delivery 4
• Inability to bear weight or ambulate due to pelvic instability 3, 2
• Pain with leg movement and difficulty with basic mobility 3

Associated Injuries

• Sacroiliac joint widening (3-5 mm) frequently accompanies large symphyseal separations 3
• Urinary and fecal incontinence can occur in severe cases, though these typically resolve with treatment 5

Long-Term Complications Without Adequate Treatment

Musculoskeletal Sequelae

• Chronic pelvic girdle pain persisting beyond the postpartum period 1, 6
• Scoliotic deformation of the lumbar spine secondary to altered biomechanics 2
• Leg length discrepancy from persistent pelvic asymmetry 2
• Chronic instability requiring repeat treatment in subsequent pregnancies 6, 2

Functional Impairment

• Impaired mobility and physical functioning affecting activities of daily living 1
• Dyspareunia (painful intercourse) as part of broader pelvic floor dysfunction 1
• Difficulty with childcare activities due to persistent pain and limited mobility 1

Treatment Algorithm

Initial Conservative Management (Separations <25 mm or as first-line)

• Bed rest with lateral decubitus positioning 2
• Pelvic binder application for mechanical support 3, 2
• Non-steroidal anti-inflammatory drugs for pain control 2
• Physical therapy focusing on pelvic floor strengthening 3
• Walker or assistive devices for protected weight-bearing 3

Conservative treatment typically shows progressive reduction over weeks to months 3, with most postpartum cases resolving within several months through pelvic floor muscle strengthening. 6

Indications for Surgical Intervention

Pubic symphysis plating is the modality of choice for anterior fixation when symphyseal diastasis exceeds 2.5 cm, particularly in "open book" injuries (APC-II, APC-III patterns). 1, 7 This represents a Grade 1A recommendation from the World Society of Emergency Surgery. 1

Specific Surgical Indications:

• Symphyseal separation >25 mm with pelvic instability 4
• Failure of conservative treatment with persistent pain and functional limitation 2, 4
• Rotationally unstable pelvic ring injuries (APC-II, LC-II patterns) 1, 7
• Vertically unstable patterns (APC-III, LC-III, vertical shear) requiring posterior fixation as well 1, 7

Surgical Technique

Open reduction and internal plate fixation of the pubic symphysis achieves excellent outcomes in cases of extreme rupture or failed conservative management. 4 For lateral compression patterns with rotational instability, temporary external fixation may be used adjunctively with posterior pelvic ring fixation. 1, 7

Critical Pitfalls to Avoid

Underestimating Severity

Do not dismiss symphyseal separations >25 mm as normal postpartum changes—these require active intervention to prevent chronic disability. 1, 2 While separations up to 10 mm are physiologic, larger gaps indicate structural failure requiring treatment. 3, 2

Premature Surgical Intervention

Conservative management should be attempted first in postpartum cases unless there is severe instability or associated pelvic ring injuries. 3, 2 However, do not delay surgery beyond 3 months if conservative treatment fails, as chronic instability becomes increasingly difficult to manage. 6, 2

Missing Associated Injuries

Always evaluate for sacroiliac joint widening and posterior pelvic ring injuries with imaging (X-ray and MRI), as isolated anterior injuries are uncommon in trauma settings. 1, 3, 4 Failure to address posterior instability leads to treatment failure. 1

Surgical Complications

Operative treatment carries high risk of postoperative complications including infection, hardware failure, and persistent pain. 2 This reinforces the importance of appropriate patient selection and exhausting conservative options first in postpartum cases. 2, 5

Prognosis and Recurrence

Prognosis for recovery is excellent with appropriate treatment, whether conservative or surgical. 5 However, recurrent separation can occur in subsequent pregnancies, though it is generally no worse than the initial occurrence. 5 Women with prior symphyseal separation should receive enhanced monitoring during subsequent pregnancies and consideration for elective cesarean delivery in severe cases. 2