골반 치골 결합의 비전형적 탈구

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450 대한정형외과학회지: 제 37 권 제 3 호 2002

J. of Korean Orthop. Assoc. 2002; 37: 450-2

골반골 골절 및 치골 결합부 탈구는 비교적 심한 외력에 의해 발생하는 손상으로 치골 결합부 탈구는 외회전 손상이나 전방 압박 손상에서 잘 일어 난다. 대부분의 치골 결합부 탈구는 치골 결합부 이개로, 문헌 고찰에 의하면 4예의 치골 결합부의 비전형적인 탈구(locked symphysis pubis, 한쪽 치 골이 다른 쪽 치골 후방으로 전위)가 보고되고 있으나, 도수정복술을 시행한 경우는 단 2예이다. 본 증례에서는 교통사고로 골반골 치골 결합부의 비 전형적인 탈구로, 요도파열과 양 슬관절 탈구가 동반된 상태로 내원하여 비전형적인 탈구를 도수 정복술로 치료하였기에 보고하는 바이다.

색인 단어 :골반, 비전형적인 치골결합 탈구, 도수 정복

450

- 1예 보고 -

이성락∙이봉진

제주 한라병원 정형외과

INTRODUCTION

A lateral compression injury, the most common type of disruption of the pelvic ring^4,7), usually includes a fracture of the sacrum or the posterior part of the ilium, as well as fracture of one or both pubic rami, or occasionally, fracture-dislocations through the symphysis. The locked symphysis pubis is a rare anterior arch injury³⁾. To the authors’knowledge, there were four case reports of the locked symphysis pubis^2,5,6,8), two cases were treated by closed reduction, which were not described its detail method of reduction^5,8). The current case of the locked symphysis pubis was reduced successfully with a closed maneuver.

CASE REPORT

In July 1999, a 26-year-old man, who sustained a pedestrian accident was transferred to the authors’hospital. He complained of severe pain in both knees and the pelvic area anteriorly and posteriorly, along with an inability to walk. On physical examination, tenderness was primarily in the symphysis pubis and along the left side of the sacrum. There was no radiating pain to the extremities. Neurologic examination of the lower extrem-

ities was normal. Anteroposterior, inlet, and outlet radiographs of the pelvis, supplemented with a computed tomographic (CT) scan, revealed that there had been internal rotation of the left hemipelvis (Fig. 1, 2), with a vertical fracture of the left side of the sacrum that extended through the sacral foramina and the locked symphysis pubis, i.e., disruption of the symphysis pubis included creeping of the left pubic body below the right pubic body (Fig. 2). Although there was no neurologic deficit in the lower extremities, closed or open reduction of the symphysis pubis was indicated because of the urethral injury, pain, and the severe internal rotation deformity of the left hemipelvis. A retro- grade urethrogram revealed a partial or possibly complete lacer- ation of the urethra. A suprapubic cystostomy tube was inserted. Then, under general anesthesia, the patient was placed in the supine position on the operating table. Two Schanz pins (1 mm radially preloaded 5 mm pins) were inserted at each side of iliac crest as a joystick for closed reduction. Reduction was attempted with external rotation and abduction of the left hemipelvis, but there was no movement of the left hemipelvis. Traction and abduction force was applied to the left lower extremity, with the knees and hips extended. After a few seconds of forceful traction, reduction was then achieved with heralded by a clunk. Under C-arm image intensifier, AP, inlet, and outlet views of the pelvis were obtained and the reduction was confirmed, but there was a motion at the symphysis pubis with compression and internal rotation.

An Orthofix^TMpelvic frame (EBI Medical Systems, Parsippany, NJ, USA) was applied to stabilize the pelvic ring (Fig. 3). Imme- diately after the operation, the patient had considerably less pain.

450 450 통신저자 : 이 성 락

제주도 제주시 연동 1963-2 제주 한라병원 정형외과

TEL: 064-740-5111∙FAX: 064-743-3110 E-mail: SRLee@Hallahosp.co.kr

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골반 치골 결합의 비전형적 탈구 451

Six weeks after the injury, radiographs revealed anatomic align- ment of the pelvis and healing of the sacral fracture and of the disruption of the symphysis pubis (Fig. 4). At that time, the external fixator was removed and partial weight bearing was started. Three months later, he returned to his previous employ- ment (construction engineer).

DISCUSSION

Lateral compression or internal rotation injury may be caused by a direct blow on the lateral aspect of the iliac crest or an indi- rect force through the femoral head. This produces compression fractures of the posterior complex, and fractures of the rami anteriorly⁷⁾.

The unusual features of the lateral compression injury to the

pelvis in the current patient were the symphysis pubis disruption with creeping of the left pubic body below the right pubic body, and rotatory displacement of the left hemipelvis. Despite the displacements, the disrupted structures were locked. According- ly, procedures to reduce the sacral and symphyseal displacements and relief of pain were indicated. A closed reduction was achieved;

however, the pelvis was considered to possibly unstable config- uration because of the sacral fracture and disruption of the symphysis pubis. The pelvic external fixator was applied to the Schanz pins, which had been used for joysticks for reduction.

In the locked symphysis pubis, the urethra may become kinked, interrupting the flow of urine. Reduction of the pelvis may unkink the urethra reconstituting urinary outflow²⁾. Only one case of the locked symphysis pubis without urethral injury was reported⁵⁾. In the current patient, reduction of the locked symphysis pubis was followed by complete reestablishment of

Fig. 1.The symphysis pubis was locked on this AP view of the pelvis.

Fig. 2.The left pubic body was below the right pubic body with rotation of the left hemipelvis.

R

Fig. 3.The left pubic body was no longer below the right pubic body on the inlet view of the pelvis after reduction.

Fig. 4.Six weeks after reduction, the pelvis appeared normal.

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452 이성락∙이봉진

the urethral channel. There was a case report of the locked symphysis pubis of the pelvis with palsy of the obturator nerve on the right which may have been secondary to direct compression of the nerve at the sacral fracture²⁾. In the current patient there was no neurologic injury. Sexual dysfunction is also a well-known complication of disruption of the pelvis. The incidence is reported to be as high as 50%¹⁾. However, in the current patient, there were no sexual dysfunctions including libido, erection, and ejac- ulation. The locked symphysis pubis is a rare anterior arch injury of the pelvis, always accompanied by the urethral injury and reduction was indicated for relief of pain and severe internal rotation deformity of the hemipelvis.

REFERENCES

1. Ellison M, Timberlake GA and Kerstein MD:Impotence following

pelvis fracture. J Trauma, 28: 695-696, 1988.

2. Gordon RO and Mears DC:Lateral compression injury of the pelvis. J Bone Joint Surg, 73-A: 1399-1401, 1991.

3. Kellen JF and Browner BD:Fractures of the pelvic ring. In: Browner BD, ed. Skeletal Trauma. 3rd Ed. Philadelphia, WB Saunders: 1122-1124, 1998.

4. Matta JM and Saucedo T:Internal fixation of pelvic ring fractures. Clin Orthop, 242: 83-97, 1989.

5. Robibson D, Hendel D and Halperin N:An overlapping pubic dislo- cation treated by closed reduction:Case report and review of the literature. J Trauma, 29: 883-885, 1989.

6. Shanmugasundaram TK:Unusual dislocation of symphysis pubis with locking. J Bone Joint Surg, 52-A: 1669-1671, 1970.

7. Tile M:Pelvic ring fractures. Should they be fixed? J Bone Joint Surg, 70- B: 1-12, 1988.

8. Webb P:Overlapping dislocation of the symphysis pubis. A case report. J Bone Joint Surg, 59-A: 839, 1977.

The lateral compression injury of the pelvis is common in high-speed vehicle accidents, and symphysis pubis disruption can occur with external rotation or anterior compression injury. The most common injury of the symphysis pubis is diastasis. So far, four cases of the locked symphysis pubis have been reported, and two of these were treated by closed reduction. The current case involves a 26-year-old man who experienced a lateral compression force to his pelvis and knees, and suffered a symphysis pubis disruption (locked symphysis pubis, i.e., creeping of the left pubic body below the right pubic body), urethral rupture and bilateral knee dislocation. The locked symphysis pubis was successfully reduced with a closed maneuver.

Key Words : Pelvis, Locked symphysis pubis, Closed reduction

Unusual Dislocation of the Symphysis Pubis - A Case Report -

Sung-Rak Lee, M.D. and Bong-Jin Lee, M.D.

Department of Orthopaedics Surgery, Halla General Hospital, Jeju, Korea

Address reprint requests to Sung-Rak Lee, M.D.

Department of Orthopaedics Surgery, Halla General Hospital 1963-2 Yeon-dong, Jeju 690-170, Korea

Tel : +82.64-740-5111, Fax : +82.64-743-3110 E-mail: SRLee@Hallahosp.co.kr