Pelvic insufficiency fracture with diastasis of the pubic symphysis after irradiation: a case report

A 61-year-old woman was seen with diastasis of the symphysis pubis and insufficiency fractures of the wings of both ilia after irradiation for carcinoma of the cervix. The characteristics and treatment of these fractures are discussed.

Post-radiotherapy osteomyelitis of the symphysis pubis: computed tomographic features

We report the clinical and computed tomography (CT) features of seven patients with osteomyelitis of the symphysis pubis following radiotherapy for bladder (n=4) or cervical (n=3) carcinoma. The patients presented with fistulae (n=5), pain (n=1) or small bowel obstruction (n=1) between 6 and 19 years after radiotherapy. The diagnosis was confirmed by surgery with histology or bacteriology of the symphysis pubis and/or associated abscess in all patients. In addition to bone destruction, other features identified on CT included abscesses, bowel loops adherent to the symphysis pubis and/or communicating with an abscess cavity, a soft tissue mass enveloping the residual bone, and fistulae. The combination of clinical and radiological features suggests osteomyelitis and, for patients who have had pelvic radiotherapy, this treatable condition should be included in the differential diagnosis of solitary symphysis pubis destruction.

[Compression of the urethra by an arthrotic cyst]

A case is presented of an osteoarthrotic cyst of the pubic symphysis with a diameter of 32 mm that caused urinating problems because of posterior dislocation and compression of the urethra. X-rays showed osteoarthrosis of the pubic symphysis, and the 56-year old woman had a history of separation of the pubic symphysis at the age of 28.

Vertical displacement of the symphysis pubis in unilateral open book pelvic injury

Nineteen cases of external rotation (open book) injury of the pelvis were studies retrospectively. An apparent vertical displacement of the hemipelvis was detected on anteroposterior radiographic views in association with the separation of the symphysis pubis and opening of the sacroiliac joint. This could be confused with a vertically unstable situation; however, careful examination of the radiographs revealed that the public bone on the side of injury was displaced inferiorly. The articular portion of the corresponding sacroiliac joint on computed tomography was opened anteriorly, and the hemipelvis on the same side was externally rotated in all cases (indicating that the posterior sacroiliac ligaments were intact). An anatomic study was then performed on 10 cadaveric pelves. The symphysis pubis and the anterior sacroiliac ligament on one side were sharply disrupted, and the pelvis was gradually externally rotated. The pubic bone on the side of the sacroiliac disruption displaced inferiorly as the external rotation progressed. It is important to differentiate between the inferiorly displaced pubic bone on the side of injury in cases of external rotation injury and the superiorly displaced pubic bone on the side of injury in cases of vertically unstable pelvic injuries. This may eliminate unnecessary procedures such as skeletal traction or pinning of the sacroiliac joint.

[A comparative evaluation of the optical density of the bone and cartilage tissue of human symphyses]

Roentgenodensitometric studies of osseous and cartilaginous tissues of pubic and sternal bones revealed statistically reliable differences in the relative values of optic density which help differentiate between three adult age groups: 22 to 35, 36 to 60, and over 61 years, and to recognize the local appurtenance of the examined bones and their symphyses.

Internal fixation in postpartum symphysis pubis rupture: report of three cases

We present three patients with postpartum symphysis pubis rupture whose severe complaints persisted after conservative treatment. All three ruptures were stabilized with open reduction and internal fixation. There were no postoperative problems, and implants were removed after a mean period of six months. Patients were free of complaints after implant removal. In select cases, operative treatment of postpartum symphysiolysis may be indicated.

Disruption of the pelvic ring during spontaneous childbirth. A case report

A young woman sustained disruption of the anterior pelvic ring with bony avulsion of the symphysis pubis during a spontaneous delivery. Anterior external fixation allowed a full functional recovery.

Sonographic assessment of symphyseal joint distention intra partum

OBJECTIVE

To elucidate whether there is a distention of the symphysis pubis intra partum and whether a history of pelvic pain during pregnancy is associated with increased distention during delivery.

METHODS

Using ultrasonography, the width of the symphysis pubis was measured on two occasions during delivery; firstly, upon engagement of the fetal head in the pelvic inlet, secondly, when the largest diameter of the fetal head was at the level of the ischiadic spines. The first measurement was conducted in 24 patients, the second measurement was obtained in 16 of these patients.

RESULTS

The average width of the symphysis pubis at onset of labor was 5.8 mm. The average distention of the symphysis during labor was 1.1 mm for those without pelvic pain and 0.2 mm for those with a history of pelvic pain during pregnancy (p = 0.02). Parity and ensuing birth weight had no statistically significant influence on degree of distention.

CONCLUSION

The symphyseal distention during labor is minimal regardless of parity and size of the child. No added symphyseal distensibility was found in patients with a history of pelvic pain.

The immediate treatment of pelvic ring disruption with the pelvic stabilizer

The management of the hemodynamically unstable patient with a severe pelvic ring disruption remains one of the most serious trauma emergencies. Standard resuscitation protocols may include attempted closure of the pelvic ring by the use of pneumatic anti-shock trousers, external fixation applied in the operating room, or a sheet wrapped around the patient in the emergency room. We report a case of pelvic ring disruption in which a successful clinical outcome was achieved with the emergent use of the Pelvic Stabilizer in the emergency room. The Pelvic Stabilizer is a device that can be effectively applied in the emergency room for the acute reduction and early stabilization of the displaced pelvis in a hemodynamically unstable patient. The use of a pelvic clamp can also be effective in the acute setting for a stable trauma patient with pelvic ring disruption. It rapidly reduces and stabilizes a potential cause for patient decompensation without obstructing access to further concomitant diagnostic or therapeutic interventions in the abdomen and perineum.

Fetal weight estimation by symphysis-fundus height and gestational age

A new method for estimating the fetal weight is described, based on symphysis-fundus height and gestational age. The relationship between ultrasound-estimated fetal weight, gestational age, and symphysis-fundus height was determined using multiple regression analysis in a low-risk group. The accuracy of the regression formula was tested retrospectively on two target populations: a second low-risk group and a higher risk group undergoing elective delivery. The formula overestimated weight by 3.6%. The standard deviation of the random errors for the first group was 10.3% whereas in the second it was 11.9%. Fetal weight estimation using symphysis-fundus height and gestational age can be performed with an accuracy comparable to that of ultrasound.

Specific antibiotic therapy by needle-aspiration for the treatment of osteomyelitis of the pubis. A description of two clinical cases

The authors describe two cases of osteomyelitis of the pubis, that exemplify the difficulty of differential diagnosis, as symptoms at the onset are "masked" by previous urologic pathologies (aspecific acute epididymitis and, respectively, urethritis cystica in the sequelae of radical prostatectomy). The x-ray findings for osteolysis make a local biopsy necessary; the lesion may in fact, be mistaken for a neoplasm, particularly in patients who have previously been submitted to pelvic visceral surgery for the treatment of tumor. The needle-aspiration procedure and the execution of a cultural examination, in addition to a cytological one, provide unmistakeable data for diagnosis and treatment.

Morphometric evaluation of the symphysis pubis joint

The Symphysis Pubis (SP) joint was investigated by X-ray in 96 adults without any history of disease of the joints. We evaluated the width of this joint by measuring the distance between the two articular surface at three points. We calculated the mean for the three interpubic distances and carried out statistical analysis so as to evaluate if there is a significative difference between the four age classes (< 50; 50-59; 60-69; > 70) and between males and females. We did not found statistically-significative differences between males and females, and between the age classes; nevertheless, it is to be noted that a slight widening of the SP joint can be seen in the elderly, which is thus not significant. We also noted that the medium part of the SP joint undergoes a larger widening in older people: this is probably due to degenerative changes in the fibrocartilagineous disc and the ligaments.

[Outcome evaluation after unstable injuries of the pelvic ring]

Open reduction followed by internal fixation is the method of choice after unstable pelvic ring fractures and gives better results than either conservative treatment or external fixation alone. Even after anatomic reconstruction of the pelvic ring, however, a high incidence of late sequelae is reported, especially after C-type fractures (translational instability). The purpose of the study reported in this paper was evaluation of a new scoring system for the rating of the long-term outcome after pelvic fractures. In all, 28 B-type fractures and 27 C-type fractures (Tile) were subjected to surgical stabilization in 1985-1990 (both external and internal stabilizations). These patients were followed up clinically and radiologically an average of 28 months after injury. The results were summarized in a new pelvic outcome score. The scoring included the radiological result (I = max. 3 points) and the clinical result with rating of function, neurological, urological and sexual deficits (II = max. 4 points). The "critical value" for the radiological evaluation was a 5-mm residual posterior displacement or a 15-mm anterior displacement in the pelvic ring defining a "poor" result (1 point). Social reintegration, an overall reflection of all accident-related sequelae, was rated independently (III = max. 3 points). I + II were summarized as "pelvic outcome," with 7 points rated as excellent, 6 points as good, 5 and 4 points as moderate, and 3 and 2 points as a poor result. Freedom from pain was achieved in 89% of the patients who had B-type injuries, and in 30% of those with C-type injuries. Neurological deficits were seen in 32% after B-type (only sensory) and 70% after C-type fractures (33% motor nerve, 37% sensory). The maximum radiological rating was given to 86% of the patients after B-type and 27% after C-type injuries. The clinical rating was maximum (4 points) in 18% after B-type and 7% after C-type fractures, resulting in a good or excellent rating for "pelvic outcome" in 79% after B-type and only 27% after C-type injuries. The maximum rating for social reintegration was given to 57% after B-type and 44% after C-type injuries. Even after anatomical reconstruction of the pelvic ring in C-type fractures (3 points) 20% of the patients were clinically rated as "poor" (1 point). The study showed that anatomic reconstruction of the pelvic ring is an important factor in a good or excellent clinical result, but even when this goal is met, other parameters (sacral fractures, SI dislocations, primary neurological/urological injuries) can lead to an unsatisfactory result. The new rating system is comprehensive and easy to apply and allows a clear differentiation of typical late sequelae after pelvic injuries; it will therefore be used for further long-term studies.

[Value of ultrasound examination in injuries of the symphysis]

Lesions of the symphisis are usually diagnosed by a pelvis X-ray. The use of ultrasound examination is not very common. The application of the ultrasonic head in a suprasymphyseal manner will result in good images of the anterior pelvis. The outcome of diastasis as well as of the edge of the symphysis measurements taken by ultrasound were comparable to the X-ray picture. Therefore ultrasound investigation is usefull for primary diagnosis and follow-up examination in injuries of the symphysis. Accompanying fractures of the pelvic ring stay in this case undetected.

Sports-related groin pain: evaluation with MR imaging

Our purpose was to assess the role of MRI in evaluating the musculoskeletal system in athletes with chronic pain laterally in the groin of unknown etiology. Magnetic resonance imaging (MRI) of the pubic ring was performed in 11 young athletes (soccer players) with long-standing groin pain. MR findings were compared with plain films and isotope examination (bone scan Tc 99M). Abnormal MRI findings included a broadened and irregular symphysis with a characteristic pattern of low signal intensity on T1W and high signal intensity on T2W images localized in the superior pubic ramus at a distance from the symphysis. Positive findings were also observed on plain films and on nuclear medicine studies. However, the imaging findings in the superior public ramus of the symphysis was located considerably more laterally on MRI. MRI is a valuable method for evaluating discrete and ambiguous pelvic pain in athletes, particularly for identifying concomitant changes in the superior ramus, which may give rise to long-standing pain localized laterally in the groin.

Ultrasonographic measurement of the symphysis pubis: a potential method of studying symphyseolysis in pregnancy

The width of the symphysis pubis was measured in a skeleton model using slide rule, ultrasonography and x-ray. Ultrasonography gave a 0.5-mm and x-ray a 1.0-mm narrower gap than the slide rule. Further, 15 nonpregnant females undergoing urography volunteered for an extra ultrasonography of the symphysis pubis. The widths of the symphysis as measured from the x-ray exposures and the ultrasonography were compared. Regression analysis gave a regression coefficient of 0.979 and a correlation coefficient of 0.850. Ultrasonography offers at least the same precision as x-ray for assessing the width of the symphyseal gap.

Osteomyelitis of the symphysis pubis after inguinal hernia repair

Images

Estimation of age from soft X-ray findings of Japanese pubic symphysis based on a image processing

A method for estimating the age at death through the image processing of soft X-ray pictures of pubic symphysis is reported. The collected 533 materials were sliced at the thickness of 5 mm. Prior to the image processing, subjective assessment was made on the five indices of gross morphological findings. The pictures showed roughening and darkening tendencies with age and two indices for image processing were introduced. Applying the natural logarithm to data obtained by the image processing and making regression analysis. two kinds of age estimation equations were derived in the form of; Y = -39.91 lnX + 189.63 and the estimated age Y was proportional to natural logarithm of measured indices X. The age estimation equations showed accuracies of 70% or more for the age range of +/- 5 years and 100% for +/- 8 years. The accuracy was satisfactory for age estimation in the field of person appraisal in legal medicine.

Prostate motion during standard radiotherapy as assessed by fiducial markers

From November 1993 to August 1994, 55 patients with localized prostate carcinoma had three gold seeds placed in the prostate under transrectal ultrasound guidance prior to the start of radiotherapy in order to track prostate motion. Patients had a planning CT scan before initial simulation and again at about 40 Gy, just prior to simulation of a field reduction. Seed position relative to fixed bony landmarks (pubic symphysis and both ischial tuberosities) was digitized from each pair of orthogonal films from the initial and boost simulation using the Nucletron brachytherapy planning system. Vector analysis was performed to rule out the possibility of independent seed migration within the prostate between the time of initial and boost simulation. Prostate motion was seen in the posterior (mean: 0.56 cm; SD: 0.41 cm) and inferior directions (mean: 0.59 cm; SD: 0.45 cm). The base of the prostate was displaced more than 1 cm posteriorly in 30% of patients and in 11% in the inferior direction. Prostate position is related to rectal and bladder filling. Distension of these organs displaces the prostate in an anterosuperior direction, with lesser degrees of filling allowing the prostate to move posteriorly and inferiorly. Conformal therapy planning must take this motion into consideration. Changes in prostate position of this magnitude preclude the use of standard margins.

Treatment of osteitis pubis in athletes. Results of corticosteroid injections

This study presents the results of treatment of osteitis pubis in 12 intercollegiate athletes. Early in this series, athletes were treated with prolonged rest, oral antiinflammatory medications, and hip-stretching exercises. Of the nine athletes treated in this manner, only one resumed symptom-free activity after 16 weeks of therapy; eight remained symptomatic and subsequently received a corticosteroid injection (1 ml 1% lidocaine, 1 ml 0.25% bupivacaine, and 4 mg dexamethasone) into the pubic symphysis. Of these eight athletes, three returned to full participation within 3 weeks of injection, four required a second injection to alleviate their symptoms, and one was unable to resume athletic activities despite two injections and an inguinal herniorrhaphy. In recent years, we have recommended an injection if treatment. Three athletes received a corticosteroid injection when their symptoms did not resolve. All three returned to full athletic competition within 2 weeks of the injection. The results of our study suggest that a more rapid return to intercollegiate athletics can be achieved through the judicious use of corticosteroid injections.