Wednesday, January 4, 2012

Minimally Invasive Screw Fixation of Symptomatic Pubic Ramus Nonunions

A 46 years old female had incidental trauma related to her equestrian activities. She noted some left groin pain but did not seek medical treatment initially. Several weeks later her left groin pain persisted and she consulted her local physician. 

She had a slight antalgic gait and mild tenderness to palpation of her pubis. She had no other relevant findings on physical examination an anteroposterior pelvic plain radiograph revealed no fracture or other abnormailty. 

Her pain worsened over the subsequent months and she was seen again and noted to have a more notable limp due to pain and persistent pubic tenderness. 

Another plain pelvic film identified left sided peripheral superior and mid-inferior pubic ramus fractures.  

Pelvic computed tomography confirmed the diagnosis and detailed the well-aligned hypertrophic nonunion sites. There were no other areas of fracture or instability seen on these imaging studies. 

She was not able to work or participate in her routine activities due to her left inguinal-pubic pain. A complete medical evaluation ruled out any form of metabolic bone diseases. She was counseled regarding the variety of operative and non-operative treatment options, and she chose percutaneous stabilization of the symptomatic pubic ramus nonunion sites.

At surgery, medullary screws were inserted through small stab wounds under fluoroscopic guidance to stabilize the nonunion sites. First the superior ramus site was fixed with an antegrade superior ramus medullary lag screw. The inferior ramus site was then secured using a large cortical lag screw.

Immediately after surgery, she noted good relief from her prior symptoms. She used crutches for 6 weeks thereafter limiting her weight bearing to light pressure only during the stance phase of gait. During weeks 7-12 after surgery, she progressed from partial weight bearing to full weight bearing along with light strengthening exercises.

Four months after surgery, she had radiographic union at the nonunion sites, no pain complaints, and had returned to her previous job and recreational impact activities.

Authored By: M.L. Chip Routt, Jr., M.D.