Embarazo y ortopedia / Pregnancy and Orthopaedics

Introducción: Son múltiples las afecciones ortopédicas que sufre una mujer embarazada, por ello las demandas de atención por esta causa van en ascenso. Objetivo: Actualizar el tratamiento de las lesiones traumáticas y ortopédicas en la paciente embarazada y coordinar las indicaciones de la cesárea. Métodos: Se utilizan métodos teóricos y empíricos para realizar análisis del conocimiento actualizado sobre estas. Resultados: Se determinó que el parto normal es posible después de una fractura pélvica, siempre que no existan secuelas que dañen el canal del parto. El dolor de espalda fue un síntoma común en las mujeres embarazadas, pero en las que presentaron escoliosis las molestias fueron más frecuentes. La diastasis de la sínfisis del pubis se asoció con la maniobra de McRoberts; y la indicación de cesárea se sugirió a partir de criterios puramente obstétricos, aunque se respetaron las afecciones ortopédicas y traumáticas presentes en las pacientes. Conclusiones: Incrementar los conocimientos del personal que trabaja con la embarazada, a partir de sus factores de riesgo y las posibilidades de mitigación de daño por estas causas.

Introduction: pregnant women suffer from multiple orthopaedic conditions; therefore, care demands for this cause are on the rise. Objective: to update the treatment of traumatic and orthopaedic injuries in pregnant patients and coordinate the indications for cesarean section. Methods: theoretical and empirical methods were used to carry out the analysis of updated knowledge regarding these affections. Results: we determined that normal delivery is possible after a pelvic fracture, as long as there are no sequelae that damage the birth canal. Back pain was a common symptom in pregnant women but in those with scoliosis the discomfort was more frequent. Symphysis pubis diastasis was associated with the McRobert's maneuver; and the indication for cesarean section was suggested based on purely obstetric criteria, although the orthopaedic and traumatic conditions present in the patients were respected. Conclusions: to increase the knowledge of the personnel, who work with the pregnant women, based on their risk factors and the possibilities of mitigating damage due to these causes.

Outcome of Internal Fixation and Corticocancellous Grafting of Symphysis Pubis Diastasis Which Developed after Malunion of Pubic Rami Fracture / 대한고관절학회지

We report a case of pubic symphysis diastasis, which was initially asymptomatic; however, it became symptomatic with urinary incontinence during pregnancy. The patient was treated with open reduction and internal fixation of the symphysis pubis. A corticocancellous autograft was used for filling the gap which remained despite bilateral compression of the iliac bones. We obtained satisfactory outcome in terms of symptoms at the 3 years' follow-up; however, there was instability findings in the X-rays with broken screws. We conclude that asymptomatic pubic symphysis diastasis might be symptomatic after additional trauma (such as pregnancy) in the following days, if it was unstable in the very beginning of injury. Fixation of old pubic symphysis diastasis with reconstruction plate by filling the gap by using corticocancellous autograft, might not prevent ultimate implant failure if the symphysis pubis diastasis is part of an unstable pelvic fracture in the very beginning.

Underestimated Sacroiliac Joint Lesion on Computed Tomography in Pelvic Open-book Injury: A Case Report / 대한고관절학회지

The classification of anteroposterior compression (APC) injury type is based on using static radiographs, stress radiographs are known as a useful adjunct in classifying type of APC pelvic injuries. According to a recent article, the intraoperative stress examination has led to a change in the treatment plan in more than 25% of patients on 22 patients presumed APC type I (symphyseal diastasis <2.5 cm) injuries. Here authors present a case demonstrating a necessity of intraoperative stress test for excluding concealed posterior ring disruption.

Incidence and Risk Factors of Symptomatic Peripartum Diastasis of Pubic Symphysis

This study was undertaken to determine incidence, associated risk factors, and clinical outcomes of a diastasis of pubic symphysis. Among 4,151 women, who delivered 4,554 babies at the Department of Obstetrics of Seoul National University Bundang hospital from January 2004 to December 2006, eleven women were diagnosed as having a symptomatic diastasis of pubic symphysis. We estimated the incidence of the diastasis and identified the associated risk factors. To evaluate the pain relief and reduction of diastasis we followed up the 11 diastatic patients. The incidence of the diastasis was 1/385. Primiparity (P = 0.010) and twin gestation (P = 0.016) appeared as risk factors for diastasis by univairable analysis; and twin gestation appeared to be the only risk factor (P = 0.006) by logistic analysis. Two patients were operated due to intractable pain; and the remaining nine patients were treated conservatively. The diastatic gap decreased to less than 1.5 cm by 2 to 6 weeks after the diagnosis and then remained stationary. At a mean follow-up of 22.1 months (range, 12 to 47 months), five of 11 patients had persistent symphysis pubis dysfunction. Diastasis is more frequent than generally acknowledged. Pregnant women with multiple gestations should be informed about the potential risk of pubic symphysis diastasis.

Spontaneous urinary voiding of metallic screws in a patient with symphyseal plating for type II pelvic ring disruption / 中华创伤杂志(英文版)

With rapid advancement in surgical techniques and improvement in implant materials, rate of internal fixation for pubic symphyseal disruption in rotationally and vertically unstable pelvic ring injuries has increased. Among various modes of implant failure, screw/plate breakage and loosening are common complications following unstable fixation. Migration of loose screws into the urinary bladder has been reported as an extremely uncommon complication of pubic symphyseal plating. Here we present a case report of a 52-year-old female who presented with asymptomatic passage of screws in her urine following migration into the bladder, 2 years after symphyseal plating for pubic diastasis in an anteroposterior compression pelvic ring injury.

Application of internal fixation for injuries of pelvic anterior ring through minimally invasive ilioinguinal approach / 中国骨伤

<p><b>OBJECTIVE</b>To evaluate the reliability of limited open reduction and minimally invasive plate osteosynthesis (MIPO) for injuries of pelvic anterior ring and to explore its operative techniques and therapeutic efficacy.</p><p><b>METHODS</b>From March 2009 to March 2012,20 patients with injuries of pelvic anterior ring were surgically fixed with reconstructive plates through minimally invasive ilioinguinal approach. There were 13 males and 7 females with an average age of 41.6 years ranging from 25 to 61 years. According to classification of Tile, there were 5 cases of type A2, 2 cases of type B1, 9 cases of type B2, 1 case of type B3, 3 cases of type C1. Including 15 cases with anterior ring fracture, 2 cases with anterior ring fracture combined with pubic symphysis separation, and 3 cases with anterior and posterior fractures. Operation time, intra-operative blood losing, injuries of femoral nerve and iliac blood vessels, condition of fracture reduction were observed.</p><p><b>RESULTS</b>All wounds healed at one stage. No complications such as infection or deep venous thrombosis occurred. According to Matta criterion of fracture reduction, 12 cases got excellent results, 7 good, 1 fair. Eighteen patients were followed up from 6 to 32 months with a mean of 16.3 months. According to functional score of Majeed, 15 cases obtained excellent results and 3 good,with an average score of 94.3 +/- 6.0.</p><p><b>CONCLUSION</b>The modified ilioinguinal approach has advantage of short operation time, less blood losing,minimally invasive in treating injuries of pelvic anterior ring and can obtain satisfactory outcomes.</p>

Anatomical Study of Symphysis Pubis Using 3 Dimensional Computed Tomography in Koreans

PURPOSE: To acquire anatomical data for the normal pelvic bone structure using three-dimensional computed tomography (3D CT) and to propose the most appropriate angle and screw length for safe screw insertion during symphysis pubis plating. MATERIALS AND METHODS: We performed 3D CT analysis in 52 patients who required plating and selected a medial and lateral insertion point between the symphysis pubis and the pubic tubercle. Using a three-dimensional medical image analysis program, we evaluated the appropriate screw length, sagittal angle, and oblique angle at each point in this cohort. RESULTS: At the medial point, the sagittal angle was determined to be 49.1degrees with an average screw length of 49.4 mm. At the lateral point, we calculated an average screw length of 49.1 mm, oblique angle of 23.2degrees, and sagittal angle of 45.7degrees. The screw length was longer in men than in women (4.6 mm and 7.3 mm, respectively) at the medial and lateral point. CONCLUSION: At the symphysis pubis diastasis, we can insert the screw caudally at 49degrees with a minimal length of 37 mm at the medial point. We can insert the screw caudally at 46degrees, medially at 23degrees, with a minimal 34 mm length at the lateral point.

Variaciones morfológicas en la sínfisis pública humana: serie de casos / A case-series of morphological variations in human symphysis pubis

Objetivo: estudiar la cara posterior del disco sinfisiario púbico en cadáveres humanos adultos con el propósito de hallar posibles variantes anatómicas. Metodología: se disecó la región de la articulación interpúbica y se evaluaron las características anatómicas. Se estudiaron cincuenta y tres sínfisis púbicas (4 femeninas y 49 masculinas) mediante abordaje anatómico, incidiendo la pared abdominopélvica con el fin de despejar los elementos asociados al pubis. Resultados: el examen macroscópico de la sínfisis púbica mostró un aspecto uniforme y liso en su cara posterior, excepto en dos cadáveres de sexo masculino. Uno de ellos presentaba dos protuberancias nodulares contiguas de distinto tamaño y alineadas verticalmente sobre la cara posterior del disco sinfisiario, mientras que otro cadáver presentó un reborde, a manera de cresta, orientado también verticalmente sobre la cara posterior de dicho disco. Las dos protuberancias halladas presentaron comunicación directa con el interior del disco sinfisiario, a manera de ampulaciones, con líquido intraarticular derivado del esbozo de cavidad que posee el disco. Conclusión: las nodulaciones y el reborde descritos podrían corresponder a alteraciones patológicas articulares como diastasis púbicas, pero sin separación de los cuerpos del pubis.

Objective: studying the posterior side of the pubic symphysis (joint containing a fibrocartilaginous disc) in adult human corpses to find possible anatomical variations. Methodology: the posterior side of the symphyseal joint was dissected and its anatomical characteristics were evaluated. Fifty-three pubic symphyses (4 females and 49 males) were evaluated in an anatomic approach by making an incision in the abdominal-pelvic wall to reveal elements associated with the pubis. Results: macroscopic examination of the pubic symphysis revealed uniform, smooth posterior faces, except in two male cadavers. One of them had two, different sized, contiguous nodular protuberances which were vertically aligned on the posterior face of the symphysis disc whilst the other cadaver presented a border, in the form of a crest, also vertically orientated on the posterior face of such disc. Both protuberances so found had direct communication within the symphysis disc, like ampoules, with intra-articular liquid derived from the outlined disc’s cavity. Conclusion: the nodulations and border described above could have corresponded to articular pathological alterations, such as pubic symphysis diastasis, but without being separated from the body of the pubis.

Diastasis congénita de la sínfisis púbica: reporte de un caso y análisis de la literatura médica / Congenital Diastasis of pubic sínfisis it: report of a case análisis y de la literature

Se presentó una niña que entró a los 8 meses de edad con extrofia cloacal y vesical e imposibilidad para el gateo y la marcha, que ingresó sentada con un arrastre continuo sobre un colchón visceral. Los estudios radiográficos iniciales de malformaciones óseas asociadas mostraron un doble sacro y displasia de las caderas en desarrollo, por lo cual se practicó una técnica quirúrgica de osteotomía bilateral pélvica tipo “pivote” parasacroilica. Se describe la historia clínica de la paciente que fue intervenida con la ayuda de cirugía pediátrica en la Clínica del Niño con un tiempo de seguimiento postoperatorio de dieciséis (16) meses, se analiza una forma de osteotomía pélvica como una opción más para estos pacientes. Igualmente se revisa la literatura de estas lesiones congénitas y su manejo.

Risk factors for lower urinary tract injuries in patients with traumatic pelvic fractures / 대한비뇨기과학회지

For identification of the risk factors for lower urinary tract injuries in patients with pelvic fractures, we reviewed the records of 332 patients with pelvic fractures and 60 patients with urethral or bladder ruptures not associated with pelvic fractures seen at our hospital during recent 5 years. The incidence of lower urinary tract injuries in patients with pelvic fractures was 9.9 per cent (urethra 57.6 per cent, bladder 36.4 per cent. and both 6.0 per cent).Of the 181 simple rami fractures 21 (11.6 percent) had lower urinary tract injuries. Of the 90 rami fractures combining other fractures 11 (12.2 per cent} had lower urinary tract injuries, especially 5 (50.0 per cent) of the 10 combining symphysis pubis diastasis. Of the 14 bladder ruptures 13 had gross hematuria, and of the 21 urethral ruptures all had blood at urethral meatus. For evaluation of significance of hematuria as a indicator for bladder ruptures, we reviewed 257 pelvic fractures without urethral ruptures and upper tract injuries. While of the 25 cases with gross hematuria 13 (52.0 percent) had bladder ruptures, of the 76 cases with only microscopic hematuria 1 case had bladder rupture. We conclude that the high risk factors for lower urinary tract injuries in patients with pelvic fractures are both rami fracture, dispacement of hemipelvis, and symphysis pubis diastasis. Therefore prompt diagnostic procedures for urethral and bladder ruptures must be performed in those cases, especially when combined with gross hematuria or blood at urethral meatus.