What is the recommended treatment for a separated pubic symphysis?

Treatment for Separated Pubic Symphysis

For pubic symphysis diastasis >2.5 cm, open reduction and internal fixation with symphyseal plating is the definitive treatment; for diastasis <2.5 cm without posterior ring instability, conservative management with protected weight-bearing and pelvic binder is appropriate. 1

Initial Assessment and Hemodynamic Stabilization

The first priority is determining hemodynamic stability and ruling out life-threatening hemorrhage, as pelvic trauma can be lethal. 1

• Hemodynamically unstable patients (systolic BP <90 mmHg, HR >120 bpm, evidence of shock) require immediate resuscitation with massive transfusion protocol, pelvic binder application, and hemorrhage control before definitive fixation. 1
• Evaluate posterior ring integrity through CT imaging—sacroiliac joint disruption or sacral fractures mandate surgical fixation even if anterior separation appears minor. 2
• Screen for urogenital injuries (present in 4-15% of pelvic fractures), particularly with bilateral pubic rami fractures; perform retrograde urethrography before catheter placement if meatal blood is present. 1, 2

Treatment Algorithm Based on Diastasis Width

Diastasis <2.5 cm (Stable Pattern)

Conservative management is appropriate when posterior ring is intact: 1, 2

• Weeks 0-6: Touch-down to partial weight-bearing (20-30% body weight) with pelvic binder for compression and pain control. 2, 3
• Weeks 6-12: Advance to 50% weight-bearing, increasing by 25% every 2 weeks based on pain tolerance. 2
• Radiographic monitoring: Obtain plain films at 2,6, and 12 weeks to detect progressive widening indicating treatment failure. 2
• Analgesia: NSAIDs and rest as needed for pain control. 4

Diastasis >2.5 cm (Unstable Pattern)

Surgical fixation with symphyseal plating is the standard of care: 1

• Pubic symphysis plating via open reduction and internal fixation is the modality of choice for "open book" injuries with diastasis >2.5 cm (APC-II, APC-III patterns). 1
• Posterior ring fixation must be addressed if sacroiliac disruption or sacral fractures are present—options include iliosacral screw fixation, spinopelvic fixation, or tension band plating. 1
• Timing considerations: Hemodynamically stable patients can undergo early definitive fixation within 24 hours; unstable or coagulopathic patients require successful resuscitation first, with fixation postponed until after day 4 in physiologically deranged polytrauma patients. 1

Pregnancy-Related Symphyseal Separation

Postpartum pubic symphysis diastasis represents a distinct clinical entity requiring modified management:

• Physiologic separation up to 10 mm during pregnancy/delivery is normal; widening >10 mm constitutes pathologic diastasis. 3, 4
• Conservative treatment with pelvic binder, lateral decubitus positioning, NSAIDs, and protected weight-bearing is first-line for most cases. 3, 4, 5
• Surgical intervention should be reserved for failed conservative management with persistent pain, locomotion difficulties, or development of secondary complications (scoliosis, leg length discrepancy). 4
• Prognosis: Recovery is generally excellent with conservative management; recurrence in subsequent pregnancies is possible but typically no worse than initial occurrence. 5

Critical Pitfalls to Avoid

• Missing posterior ring instability is the most dangerous error—an isolated-appearing anterior disruption may conceal destabilizing posterior injury requiring operative fixation. 2
• Premature weight-bearing advancement can cause displacement and convert stable to unstable patterns; strict adherence to pain-guided protocols prevents this. 2
• Urethral catheterization before imaging when urethral injury is suspected can worsen the injury; always perform retrograde urethrography first if meatal blood is present. 1, 2
• Delayed hemorrhage control in unstable patients—if angioembolization cannot be performed within 60 minutes, preperitoneal pelvic packing with external fixation should be considered as temporary hemostasis. 1

Surgical Fixation Options

Multiple technical approaches exist for definitive fixation: 1

• Anterior fixation: Symphyseal plating (standard), percutaneous cannulated screws (minimally invasive alternative), or minimal-invasive internal fixators. 6
• Posterior fixation: Iliosacral screw fixation, spinopelvic fixation (allows immediate weight-bearing in vertically unstable sacral fractures), or tension band plating. 1
• External fixation: May be used as temporary adjunctive stabilization for selected lateral compression injuries with rotational instability (LC-II, LC-III), typically for 6 weeks. 1, 7

The goal of internal fixation is anatomic reduction with stable fixation to enable early functional rehabilitation and minimize long-term morbidity, chronic pain, and complications from prolonged immobilization. 1