Case Reports
Traumatic Disruption of Pubis Symphysis With Accompanying Posterior Pelvic Injury After Natural Childbirth
Am J Orthop. 2007 November;36(11):E167-E170
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Christian Hierholzer, MD, Arif Ali, MD, Jose B. Toro-Arbelaez, MD, Michael Suk, MD, JD, MPH, and David L. Helfet, MD
Dr. Hierholzer is Attending Orthopedic Surgeon, BG-Unfallklinik Murnau, Murnau, Germany.
Dr. Ali is Attending Orthopedic Surgeon, Division of Orthopedics, Lutheran General Hospital, Park Ridge, Illinois.
Dr. Toro-Arbelaez is Assistant Professor of Orthopedics, Albert Einstein College of Medicine, and Attending Orthopedic Surgeon, Jacobi Medical Center, Bronx, New York.
Dr. Suk is Assistant Professor of Orthopedics, University of Florida College of Medicine, and Director of the Orthopaedic Trauma Service, The Bone & Joint Institute at Shands, Jacksonville, Florida.
Dr. Helfet is Professor of Orthopaedic Surgery, Weill Medical College of Cornell University, New York, New York, and Director, Orthopaedic Trauma Service, the Hospital for Special Surgery and New York Presbyterian Hospital, New York, New York.
Abstract not available. Introduction provided instead.
Parturition-induced pelvic instability is a rare pathogenetic entity. Reports of the incidence of symphyseal rupture after vaginal delivery have varied from 1 in 300 to 1 in 30,000 deliveries.1-6 The extent of symphyseal changes during pregnancy and delivery may vary significantly. Peripartum ligamentous relaxation with moderate widening of symphysis pubis and sacroiliac (SI) joints is physiologic and occurs regularly.7,8 Anterior separation of the pubic symphysis of more than 2.5 cm progressively causes injury to the posterior pelvic ring, including disruption of the SI joint or sacral fractures.9 When symphyseal rupture does occur, it typically happens during delivery or shortly after labor and is characterized by a sharp and immediate onset of severe pain over the pubic symphysis and may extend posteriorly into the SI joint region accompanied by an audible crack. Treatment of a ruptured pubic symphysis is predominately nonoperative and consists of pelvic binder application, immobilization and bed rest, analgesia, and physical therapy.10 Operative treatment has been described in selected cases, particularly when nonoperative treatment is unsuccessful.1,11,12 Symphyseal rupture that may indicate posterior pelvic arch instability requires reduction and stable fixation. These injuries result in an unstable pelvic disruption and may correspond to traumatic anteroposterior compression (APC) II or III or Tile type B or C pelvic injuries.9,13 These women should be managed as one would a trauma patient with a pelvic fracture—including vigilant monitoring of hemodynamic status and aggressive resuscitation, appropriate diagnostic imaging studies, and timely operative reduction and fixation of the pelvis. In this report, we present the case of a woman in her early 30s suffering from traumatic symphysis diastasis with accompanying disruption of left and right SI joints after natural childbirth. The patient, who was successfully treated with open reduction and internal fixation (ORIF) of the symphysis and percutaneous screw fixation of the SI joints, recovered from this disabling injury.