Locked pubis symphysis in a skeletally immature patient, a case report

Abstract

Background: Locked symphysis pubis is an exceedingly rare pelvic injury especially in the paediatric population. This study is the first to describe this fracture in a skeletally immature patient.

Case report: We report the case of a fifteen year old boy who presented to the Emergency Department (ED) after being involved in a farming injury with a left lateral compression pelvic trauma. He sustained Locked Symphysis Pubis (LSP) and internal pelvic bleeding from the right Internal Iliac Artery (IIA). He was treated successfully by selective embolization of the ILA followed by closed reduction of the LSP and percutaneous fixation of the SI joint.

Conclusion: Locked symphysis pubis in the paediatric population is an exceedingly rare injury among lateral compression type pelvic fractures. Careful assessment and preoperative management planning are encouraged. Open packing of the pelvis in case of internal bleeding should be avoided in paediatric patients, only selective embolization is advocated. Closed reduction of the LSP by using the external fixator as a lever arm for reduction followed by percutaneous fixation of the SI joint. Moreover, changing the patient position to prone position followed by posterior lumbar spine stabilisation is our preferred method of treatment.

Keywords: Case report; Locked pubic symphysis; Overlapped pubic symphysis; Pelvic fracture; Spine fracture.

Fig. 1

Plain films demonstrated fractures left sacrum and iliac bone and LSP.

Fig. 2

CT scan of the pelvis shows displaced fracture of the left iliac bone, commuted left sacral ala fracture, minimally displaced right-sided sacral ala fracture and complete rupture of the pubic symphysis with LSP.

Fig. 3

CT scan of the lumbosacral spine shows complete burst fracture of the L3 vertebral body extending into both pedicles, with significant 1.2 cm osseous retropulsion within the canal and resultant compression of the cauda equina nerve roots, further burst fracture of the L 4 vertebral body and minimally displaced transverse process fractures of the right L1-L4 vertebrae.

Fig. 4

Selective embolisation of the right internal iliac artery by using 6 mm pushable Azur CX coils.

Fig. 5

post operative radiograph with external fixator and two sacoilliac screws in situ and clips for the posterior branch of the right internal iliac artery.

Fig. 6

intraoperative radiograph shows fixation of the sacroilliac joint with two percutanous cannulated screws.

Fig. 7

post-operative radiograph of the left distal femur with external fixator in situe.

Fig. 8

Intraoperative radiograph shows posterior stabilisation from L1 to L5.

Fig. 9

Post-operative radiograph (eight weeks) of the pelvis and left femur, shows posterior stabilisation from L1 to L5, external fixation in situ of the pelvis and left femur.

Fig. 10

post-operative radiograph of the left distal femur after removal of external fixator (8 weeks).

Fig. 11

post-operative radiograph (after one year) of the lumbar spine, pelvis and left femur shows satisfactory healing and alignment.