Pubic symphysis diastasis: Difference between revisions
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===History and Physical Exam=== |
===History and Physical Exam=== |
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Patients often will present to their health care provider with the aforementioned signs and symptoms. In addition, providers can ask patients targeted questions to obtain additional information regarding their pelvic pain. Questions related to specific movements such as climbing stairs, turning in bed, changes in gait and stride length, pain with carrying any weight, or difficulty urinating or defecating{{Citation needed|date=March 2022}}. |
Patients often will present to their health care provider with the aforementioned signs and symptoms. In addition, providers can ask patients targeted questions to obtain additional information regarding their pelvic pain. Questions related to specific movements such as climbing stairs, turning in bed, changes in gait and stride length, pain with carrying any weight, or difficulty urinating or defecating should be discussed when obtaining a history of present illness from these patients{{Citation needed|date=March 2022}}. |
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Manual testing by a healthcare professional can also be used. The patient is placed in various positions and pressure is applied in such a way that it provokes pain and maybe movement in the pubis.{{citation needed|date=August 2021}}. Physical exam special tests include point tenderness when the pubic symphysis is palpated, a positive Trendelenburg sign, and a positive Patricks Faber test{{Citation needed|date=March 2022}}. Practitioners may also appreciate a palpable gap when examining the mons pubis. Other observations may include erythema and swelling to the area as well. |
Manual testing by a healthcare professional can also be used. The patient is placed in various positions and pressure is applied in such a way that it provokes pain and maybe movement in the pubis.{{citation needed|date=August 2021}}. Physical exam special tests include point tenderness when the pubic symphysis is palpated, a positive Trendelenburg sign, and a positive Patricks Faber test{{Citation needed|date=March 2022}}. Practitioners may also appreciate a palpable gap when examining the mons pubis. Other observations may include erythema and swelling to the area as well. |
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===Imaging=== |
===Imaging=== |
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This abnormally wide gap can be [[diagnosis|diagnosed]] by [[radiology|radiologic]] studies such as [[X-ray]], [[Ultrasound]], [[MRI]], [[CT scan]] or [[bone scan]]. While X-Ray is the gold standard to identify a separation of the pubic symphysis, a decision must be made in regard to which imaging modality to utilize that is patient and case-specific{{Citation needed}} |
This abnormally wide gap can be [[diagnosis|diagnosed]] by [[radiology|radiologic]] studies such as [[X-ray]], [[Ultrasound]], [[MRI]], [[CT scan]] or [[bone scan]]. While X-Ray is the gold standard to identify a separation of the pubic symphysis, a decision must be made in regard to which imaging modality to utilize that is patient and case-specific{{Citation needed}}. |
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==== X-ray ==== |
==== X-ray ==== |
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==== CT scan and MRI ==== |
==== CT scan and MRI ==== |
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Both diagnostic machines can produce detailed cross-sections of the pelvic area. Images will show degrees of soft tissue injury, inflammation of the [[subchondral bone|subchondral]] region and the bone marrow <ref>Magnetic resonance imaging changes of sacroiliac joints in patients with recent-onset inflammatory back pain: inter-reader reliability and prevalence of abnormalities. ''[[Arthritis Research & Therapy]]'' 2006, 8:R11 {{doi|10.1186/ar1859}}. Liesbeth Heuft-Dorenbosch1, René Weijers, Robert Landewé1, Sjef van der Linden1, Désirée van der Heijde1</ref> and any abnormal posturing of the pelvic joints. MRI can show a more detailed view of soft tissue injuries that may be associated with pubic symphysis diastasis, and |
Both diagnostic machines can produce detailed cross-sections of the pelvic area. Images will show degrees of soft tissue injury, inflammation of the [[subchondral bone|subchondral]] region and the bone marrow <ref>Magnetic resonance imaging changes of sacroiliac joints in patients with recent-onset inflammatory back pain: inter-reader reliability and prevalence of abnormalities. ''[[Arthritis Research & Therapy]]'' 2006, 8:R11 {{doi|10.1186/ar1859}}. Liesbeth Heuft-Dorenbosch1, René Weijers, Robert Landewé1, Sjef van der Linden1, Désirée van der Heijde1</ref> and any abnormal posturing of the pelvic joints. MRI can show a more detailed view of soft tissue injuries that may be associated with pubic symphysis diastasis, and is radiation-free, thus making this imaging modality ideal for the pregnant patient{{Citation needed}} |
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==Management== |
==Management== |
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Revision as of 19:49, 9 March 2022
| Diastasis symphysis pubis | |
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| Post traumatic diastasis of symphysis pubis | |
| Specialty | Orthopaedic |
Diastasis symphysis pubis is the separation of normally joined pubic bones, as in the dislocation of the bones, without a fracture that measures radiologically more than 10 mm. Separation of the symphysis pubis is a rare pathology associated with child birth and has an incidence of 1 in 300 to 1 in 30,000 births. It is usually noticed after delivery but can be observed up to 6 months postpartum.[1] Risk factors associated with this injury include cephalopelvic disproportion, rapid second stage of labor, epidural anesthesia, severe abduction of the thighs during delivery or previous trauma to the pelvis. Common signs and symptoms include symphyseal pain aggravated by weight bearing and walking, a waddling gait, pubic tenderness, and a palpable interpubic gap. Treatment for diastases symphysis pubis is largely conservative, with treatment modalities including pelvic bracing, bed rest, analgesia, physical therapy and in some severe cases, surgical.[2]
Mechanism
A specific cause for the separation of the pubic symphysis during pregnancy and delivery has not been identified by researchers as of date. Thoughts surrounding the hormone relaxin and its effect on the laxity of ligaments during pregnancy have been investigated, but no direct cause of this hormone to pubic symphysis diastasis has been identified. Relaxin, in conjunction with progesterone, can cause a physiological separation of the pubic symphysis during pregnancy that typically measures 3-5mm and is most pronounced in the first trimester and returns to normal size within 5 months postpartum
Risk factors associated with the condition have been identified and include cephalopelvic disproportion, large fetuses, epidural anesthesia, the use of forceps, primigravida, multiple gestations, previous of difficult delivery such as shoulder dystocia, and previous pre-existing pelvic injury or pathology. Risk factors related diastasis of the pubic symphysis can further be stratified by causes including enzymatic causes such as disturbances in collage synthesis, endocrine causes related to hormones produced in pregnancy such as progesterone, estrogen and relaxin, inflammatory processes, metabolic disturbances in the production of vitamin D and calcium and pelvic instability such as congenital malformations and excessive lumbar lordosis.
In addition, outside of pregnancy and post-partum states, separation of the pubic symphysis can be seen in the setting of trauma. These cases are related to injuries sustained from high velocity injuries such as motor vehical accidents, falls from large heights, falling from a horse and crush injuries [3]
Signs and Symptoms
Patients can present with symptoms before, during, or after delivery, and the onset of symptoms can range from post-partum day 1 up to 6 months postpartum. Often patients present with pain shortly after the cessation of the effects of epidural anesthesia and upon ambulation. Pain is often located in the anterior pelvis and can radiate down the anterior thigh, hip, abdomen, and lower back. Patients will often exhibit tenderness to palpation of the pubic symphysis and symptoms will be exacerbated with specific movements such as the transition from lying down to sitting and standing, climbing stairs, or lifting heavy loads. Patients often are unable to stand on one leg and can exhibit a "waddling" gait [4]
Diagnosis
Diagnosis of Diastasis Symphysis Pubis is a clinical diagnosis determined by history and physical exam findings in conjunction with radiological findings.
History and Physical Exam
Patients often will present to their health care provider with the aforementioned signs and symptoms. In addition, providers can ask patients targeted questions to obtain additional information regarding their pelvic pain. Questions related to specific movements such as climbing stairs, turning in bed, changes in gait and stride length, pain with carrying any weight, or difficulty urinating or defecating should be discussed when obtaining a history of present illness from these patients[citation needed].
Manual testing by a healthcare professional can also be used. The patient is placed in various positions and pressure is applied in such a way that it provokes pain and maybe movement in the pubis.[citation needed]. Physical exam special tests include point tenderness when the pubic symphysis is palpated, a positive Trendelenburg sign, and a positive Patricks Faber test[citation needed]. Practitioners may also appreciate a palpable gap when examining the mons pubis. Other observations may include erythema and swelling to the area as well.
Differential diagnosis
Other diagnoses that may present similar to diastasis symphysis pubis that must be excluded prior to making a diagnosis include mechanical low back pain, perineal lacerations, sciatica, urinary tract infections, pelvic and lower extremity vein thrombosis, neoplastic processes, septic arthritis, osteomyelitis, pubic osteolysis, and osteitis pubis.[citation needed]
Laboratory tests such as a complete blood cell count looking for elevated white blood cells, inflammatory markers such as lactate, CRP, and ESR, and a urinalysis can help rule out infectious processes that may be causing pelvic pain similar in presentation to pubic symphysis diastasis[citation needed].
Imaging
This abnormally wide gap can be diagnosed by radiologic studies such as X-ray, Ultrasound, MRI, CT scan or bone scan. While X-Ray is the gold standard to identify a separation of the pubic symphysis, a decision must be made in regard to which imaging modality to utilize that is patient and case-specific[citation needed].
X-ray
An X-ray film obtained in the AP view of the pelvic inlet and outlet will show a marked gap between the pubic bones.[citation needed] A normal pelvis will show a gap that is 4–5 mm. However in pregnancy the hormonal influences cause relaxation of the connecting ligaments and the bones separate up to 9 mm. A gap measuring greater than 10 mm indicates a pathological process[citation needed].
In addition, a view in the "flamingo stance" can be obtained to demonstrate the instability of the joint. This position consists of the patient standing with weight on one leg and the other bent.[5] A vertical displacement of more than 1 cm is an indicator of symphysis pubis instability.[6] A displacement of more than 2 cm usually indicates involvement of the sacroiliac joints.[citation needed]
A limitation of this imaging study is that X-rays induce radiation and should be avoided during pregnancy[citation needed].
Ultrasound
The utilization of ultrasound to identify pathologic widening of the pubic symphysis has recently been studied and identified to be a cost-effective way to obtain imaging of the pubic symphysis, especially in the pregnant population, where the radiation should be avoided[citation needed].
CT scan and MRI
Both diagnostic machines can produce detailed cross-sections of the pelvic area. Images will show degrees of soft tissue injury, inflammation of the subchondral region and the bone marrow [7] and any abnormal posturing of the pelvic joints. MRI can show a more detailed view of soft tissue injuries that may be associated with pubic symphysis diastasis, and is radiation-free, thus making this imaging modality ideal for the pregnant patient[citation needed]
Management
Treatment include bed rest, anti inflammatory agents, physiotherapy and a pelvic corset to provide support and stability.[citation needed]
References
- ^ Herren, C.; Sobottke, R.; Dadgar, A.; Ringe, M.J.; Graf, M.; Keller, K.; Eysel, P.; Mallmann, P.; Siewe, J. (June 2015). "Peripartum pubic symphysis separation – Current strategies in diagnosis and therapy and presentation of two cases". Injury. 46 (6): 1074–1080. doi:10.1016/j.injury.2015.02.030.
- ^ Urraca-Gesto, M. Alicia; Plaza-Manzano, Gustavo; Ferragut-Garcías, Alejandro; Pecos-Martín, Daniel; Gallego-Izquierdo, Tomás; Romero-Franco, Natalia (2015). "Diastasis of symphysis pubis and labor: Systematic review" (PDF). Journal of Rehabilitation Research and Development. 52 (6): 629–640. doi:10.1682/JRRD.2014.12.0302. ISSN 0748-7711.
- ^ Williamson, Michael; Vanacore, Felice; Hing, Caroline (June 2018). "Pubic symphysis diastasis sustained from a waterslide injury". Journal of Clinical Orthopaedics and Trauma. 9: S32–S34. doi:10.1016/j.jcot.2018.01.002. PMC 6008670. PMID 29928101.
- ^ [citation needed]
- ^ An Analysis of Pubis Symphysis Misalignment Using Plain Film Radiography Ruch WJ, Ruch BM. J Manipulative Physiol Ther. 2005;28(5):330-335
- ^ Vertically Unstable Pelvic Fractures Fixed with Percutaneous Iliosacral Screws: Does Posterior Injury Predict Fixation Failure? Damian R. Griffin, MA, FRCS (Orth); Adam J. Starr, MD; Charles M. Reinert, MD; Alan L. Jones, MD; Shelly Whitlock, CCRA; University of Texas Southwestern Medical Center, Dallas, TX
- ^ Magnetic resonance imaging changes of sacroiliac joints in patients with recent-onset inflammatory back pain: inter-reader reliability and prevalence of abnormalities. Arthritis Research & Therapy 2006, 8:R11 doi:10.1186/ar1859. Liesbeth Heuft-Dorenbosch1, René Weijers, Robert Landewé1, Sjef van der Linden1, Désirée van der Heijde1
External links
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