Date: Fri, 16 Jun 2000 13:44:40 -0700
From: John Ruth
Subject: 44 year old with persistent pain following pelvic ring injury
I have just seen a 44 year old state police officer who 4 mos. ago came down hard on the front part of the saddle and then was bucked off the horse. He sustained a symphysis disruption (probably an AP-2 type injury but I don't yet have the initial films).
He was treated at another local hospital without surgery and early mobilization. He continues to complain of left SI pain and sensation of grinding as well as anterior pain with a sensation that his pelvis is unstable. He is ambulatory without aids but cannot ride and is still at a desk job at work.
I have submitted 2 radiographs taken yesterday. The first is an AP non-stressed (3 cm of symphyseal widening) and the second is an AP with medial lateral compression (1 cm of symphyseal widening). Of note the compression felt better.
My feeling is that he needs stabilization but how extensive. A simple symphyseal plating will restore his anterior ring but I am concerned that his pelvic floor and anterior SI ligaments are now healed elongated. Does he need a left SI fusion to prevent delayed anterior plate failure and recurrence of the deformity with pain or will the anterior scarring following symphyseal plating be enough for long term stability of his ring? I would appreciate any suggestions.
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Date: 16 Jun 00 14:10:42 -0800
From: M.L.Chip Routt,Jr.,M.D.
the reason his pelvis feels unstable is because it is unstable.
a routine pelvic ct would demonstrate si joint pathology/residual.
single leg standing (flamingo) ap pelvic images for both sides (if he can), would also reveal si joint mobility.
specific treatment recs would depend on those studies' findings.
he'd benefit from treatment.
chip
Date: Fri, 16 Jun 2000 16:31:49 -0500
From: Adam Starr
I think a CT is a good idea, to evaluate the SI joint.
I don't know why we don't see more of these injuries. You would think every single bronc rider on the circuit would get this sooner or later.
I think plating his symphysis would help him. Percutaneous iliosacral screw would probably help alleviate his posterior pain, by stabilizing the SI joint. I don't think I would do an SI joint fusion.
As far as delayed anterior plate failure goes, many symphyseal plates placed for APC 2 injuries will show evidence of screw loosening 2 or 3 years after surgery. I think the symphysis wiggles under the plate - you don't fuse it, after all - and the screws can get loose.
Adam Starr, Dallas, Texas
Date: Sat, 17 Jun 2000 05:28:38 +0100
From: bruce meinhard
I once heard Marvin Tile speak about this and ,if memory serves me correctly, he had seen this after pregnancy . He recommended a longer waiting period. If the stress tests are + then you will be forced to do something before a year.
He recommended a symphyseal plate. He also cautioned about SI fusion because he said that even with solid arthrodesis they might still have posterior pain. A iliosacral screw would be reasonable. A CT would tell you if the SI joint is damaged and would be an aid in decislion making. He joked that under those circumstances, try to convince your patient that the problem is the spine, and refer it to your colleague.
bpm