Case of spontaneous pubic symphysis disruption and concomita
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Disruption of the pubic symphysis is classically associated with an anterior-posterior compression (APC) mechanism from external blunt force trauma. Pubic symphysis diastasis is also seen in the intrapartum or postpartum period of spontaneous vaginal delivery, though this is often associated with hormonal changes that cause relaxation and lengthening of ligaments.

A 54-year-old male competitive powerlifter with a past medical history of hypertension, hyperlipidemia, and coronary artery disease presented with a complaint of right greater than left lower abdominal pain. He had been performing a back-squat with 670 lbs. when he felt a painful “pop” in his lower abdomen. He also reported experiencing urinary urgency, frequency, and hematuria.

On visual inspection, there was ecchymosis at the base of his penis. No obvious scrotal swelling was seen. Initial physical examination by the ED physician was positive for abdominal distension, tenderness, and guarding, but no rebound tenderness or signs of peritonitis were elicited. CT urogram results showed a widening of the pubic symphysis measuring up to 18 mm. A close review of the CT imaging demonstrated small amounts of air in both sacroiliac joints. There was also a large intraluminal bladder hematoma taking up over 50% of the bladder volume with contrast extravasation along the right side of the retropubic space anterior to the prostate.

The patient was taken to the operating room (OR) by a urologist for cystoscopy and intraluminal hematoma evacuation. Cauterization of the bleeding was unsuccessful so the procedure was concluded and the patient was transferred to the interventional radiology suite. An arteriogram was performed which showed active extravasation of a “replaced” or “accessory” obturator artery, an anatomic variant of the obturator artery as a branch from the inferior epigastric artery rather than from the usual anterior division of the internal iliac artery.

Patient continued to experience hematuria. A low midline incision was used to enter the retropubic space and significant hematoma was evacuated. Repeat cystoscopy was performed and an additional suture was used to seal a small intraluminal leak. The retropubic space continued to ooze blood so packing was placed around the prostate and hemostasis was achieved. A temporary abdominal closure was performed with a plan to return to the OR for removal of packing material and repeat exploration.

On hospital day 3, the patient was brought back to the OR, packing material was removed, and no further bleeding was noted. At this point, the orthopedic trauma team was asked to re-examine his symphysis given the direct visualization of the pelvic ring disruption. The diastasis was measured to be 30 mm using a sterile ruler so the decision was made to proceed with plate fixation of the symphysis. This was accomplished with a Jungbluth clamp along the anterior surface for reduction and placement of a Synthes 3.5 mm 6-hole pubic symphysis plate (Synthes) with 3.5 mm Bone Screw Fasteners (OsteoCentric). A medium Hemovac drain was placed and primary closure was performed of his fascia and skin incision.
Post-operatively he was allowed to weight bear for transfers only. By 3 months following surgery, he was allowed to weight-bear as tolerated and has gone on to do well without any radiographic or clinical signs of implant failure.