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MANAGEMENT OF DIASTASIS PUBIC SYMPHYSIS: CASE REPORT

By

Bakare, Akeem

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Outline

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Introduction

Epidemiology

Aetiology

Management

Prognosis

Case Study

Conclusion

Reference

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Introduction• Rupture of pubic symphysis is uncommon

• Reported incidence: 1 in 300 deliveries (Snow and Neubert, 1997)

• Mild diastasis: less than 10 mm is considered

physiological in pregnancy• Greater separation results in tenderness and difficulty

with ambulation (Joosoph and Kwek, 2007).

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Diagnosis can be confirmed rapidly by: Pelvic X-ray. Additionally, MRI serves to exclude soft tissue

injury (Graf et al, 2014).

Introduction:

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Figure 1: Normal anatomical structure of a pelvic bone with intact pubic symphysis

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Definition:Diastasis symphysis pubis is the separation of normally joined pubic bones, as in the dislocation of the bones, without a fracture. According to Kelly et al (2002).

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Figure 2: X ray film of a diastasis pubic Symphysis of about 15mm (Graf et al, 2014)

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Figure 3: X ray film of a diastasis pubic Symphysis of about 60mm (Graf et al, 2014)

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Epidemiology• The incidence of pubic diastasis is 1 out of 800

patients in post partum stage (Scriven et al, 1995).

• In the work of Wu et al (2004), a diastasis of the symphysis pubis is a cause of pelvic girdle pain (PGP). Overall, about 45% of all pregnant women and 25% of all women postpartum suffers from PGP.

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AetiologyThis injury has also been associated with various other situations like: • Pregnancy complication• Trauma• Sport Injury • Inflammatory arthritis following long-term

corticosteroid intake. (Rommens, 1997; Mulhall et al, 2002; Tsukahara et al, 2007).

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Severity Grading and Outcome Measure

Patient can be assessed and graded pre and post management using the Clinical Scoring scale designed by Majeed (1986). The scale is described below:

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Table 1: Clinical scoring ScalePatient ability score

PainIntense, continuous at rest 0 to 5Intense with activity 10Tolerable, but limits activity 15

With moderate activity, abolished by rest 20

Mild, intermittent, normal activity 25Slight, occasional or no pain 30Maximum 30

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Sitting

Painful 0 to 4

Painful if prolonged or awkward 6

Uncomfortable 8

Free 10

Maximum 10

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Sexual Intercourse

Painful 0 to 1

Painful if prolonged or awkward 2

Uncomfortable 3

Free 4

Maximum 4

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Walking Aids

Bedridden or almost 0 to 2Wheelchair 4Two crutches 6Two sticks 8One stick 10No sticks 12

Maximum 12

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Gait Unaideds

Cannot walk or almost 0 to 2

Shuffling small steps 4

Gross limp 6

Moderate limp Slight limp 8 -10

Normal 12

Maximum 12

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Walking Distance

Bedridden or few metres 0 to 2

Very limited time and distance 4

Limited with sticks, difficult without 6

prolonged standing possible

One hour with a stick 8

One hour without sticks, slight pain or limp 10

Normal for age and general condition 12

Maximum 12

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Functional outcome (total score)

Excellent 78 to 80

Good 70 to 77

Fair 60 to 69

Poor <60

Aggarwal et al, 2011

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Outcome Residual displacementExcellent 0-5 mm

Good 6-10 mm

Fair 11-15 mm

Poor >15 mm

Table 2: Radiological outcome scores

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Aggarwal et al, 2011

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Management

Management includes: Conservative management Use of medications Surgery

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Typically, a conservative treatment is performed comprising:• Pelvic girdle,• Analgesia, • Bed rest in lateral decubitus i.e. lying on his or

her side, and • Physical therapy ( Dunbar and Ries, 2002; Jain

and Sternber, 2005; Nouta et al, 2011).

Management:

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Rehabilitation1. Bed rest2. Deep breathing exercises3. Isometric quadriceps contraction exercises4. Ankle pump exercises5. Cryotherapy6. Soft tissue manipulation to the low back and hip regions7. Transcutaneous electrical nerve stimulation to the low back and hip regions. (Okafor and Shokunbi, 2009).

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PrognosisPrognosis depends on severity of injury and it may resolve in weeks. The condition can take from 11 weeks, 6 months or even up to 2 years postpartum to subside. If detected on time and proper management channelled, prognosis is good according to Larsen et al, (2001).

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A Case Report Mrs Y was referred on account of severe pain, inability to stand unaided and inability to neither sit nor walk due to pain around the pelvic and gluteal region. The history indicated that she underwent a caesarean section after a prolonged labour at the traditional birth attendance clinic.

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The surgery was done two months before presentation at the hospital, however, several interventions had been sought to help in the post partum symptom of functional loss, which include medications and help from the traditional bone setters but to no avail.

A Case Report:

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A Case Report:At presentation, she was helped into the cubicle carried by two individuals with excruciating pain. She underwent five weeks intensive physiotherapy. After the fifth week, the pain had significantly reduced (VAS: 1/10) and had significant functional ability with Majeed Scoring Scale increasing to 77/ 80.

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Presenting Complaints:

Severe pain on the lower limbs especially the RLL for 2 months

Inability to sit and rest on the right side of the buttocks for 2 months

Inability to stand and walk on the right lower limb Extreme difficulty in lying supine, prefers to lie in

side position especially on the left

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Assessment revealed:

Antalgic gait with very short steps, nil foot drop observed

Visual analogue scale (VAS): 10/10 Gluteal tenderness greatest on the right Tenderness on the pubic symphysis Marked hypotonicity of the right thigh muscles and

gluteal muscles.

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Marked atrophy of the thigh muscles and gluteal muscles Range of motion: PROM – Hip flexion/extension limited

with painoHip abduction/adduction limited because of

painoAROM – Not possible due to pain in all

ranges Strength: not assessed because of pain.

Assessment revealed:

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Tests: Walking 10 metres distance: 11 minutes Hip Compression test: + Hip Distraction Test: patient unable to lie supine because

of pain, laid on the left side of the body Hip log roll: not assessed because of her position Gaeslens’ test: not assessed Thomas and Patrick’s test: not assessed Flamingo’s test: not done.

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X-ray: Pelvic x ray revealed widening of the pubic symphysis to 15mm: (normal > 7mm)

Hip joint spaces are preserved.

Radiological Investigation

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S/N

Outcome Measure Outcome Variables Values

1 Visual Analogue Scale ( VAS) Pain 10:10

2 Clinical Scoring Scale Functional Ability 28:80

3 Walking 10 Metres distance Time 11 minutes

4 Step Length Distance 6 inches

5 Radiological Outcome Scores Residual Displacement 15mm

Summary of assessment at first visitTable 3: Week One assessment profile

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Treatment given includes:• Cryotherapy, • TENS, • Muscle setting for quadriceps, hamstrings and

gluteal muscles, ankle pump exercises, • Soft tissue manipulation using voltaren emulgel,

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• Application of pelvic belt support, • Ambulation using walking frame, • Counseling on bed rest, • Positioning and movement of lower limbs

and Psychotherapy.

Treatment given includes:

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Treatment was progressed according to patient tolerance and level of improvement. Patient improved progressively as shown in the assessment profile column in tables 4, 5, 6,7and 8. During the week two of treatment, the gross muscle power of the lower limbs group of muscles were assessed and resistance exercises was commenced for all the weak muscles.

Treatment given includes:

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Treatment given includes:

At the end of the third week, the walking frame was discontinued and she ambulated unaided with lesser degree of difficulty; also the pelvic support was discontinued. At the end of the fourth week, patient was referred for a check x ray which revealed reduction in the diastasis gap to 4mm.

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Treatment given includes:

The patient became more stable and highly independent at the end of the fifth week of management, and her appointment was spaced out to once in a month and contact was kept via the mobile phone.

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S/N

Outcome Measure Outcome Variables Values

1 Visual Analogue Scale ( VAS) Pain 6:10

2 Clinical Scoring Scale Functional Ability 59:80

3 Walking 10 Metres distance Time 6min,58 secs

4 Step Length Distance 9 inches5 Radiological Outcome Scores Residual Displacement NA

Table 4: Week Two assessment profile

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Further assessment of muscle power was carried out because patient could move limbs more actively with lesser pain.

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Group of Muscle Tested Lower Limbs

Right LeftHip Adductors 3:5 3:5Hip Abductors 1:5 1:5Hip Flexors 3:5 3:5Hip Extensors 3:5 3:5Knee Flexors 3:5 3:5Knee Extensors 3:5 3:5Ankle Dorsiflexors 5:5 5:5Ankle Plantarflexors 5:5 5:5

Table 5: Gross Muscle Power chart for the lower limbs

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Management:Strengthening exercise program was included.

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S/N Outcome Measure Outcome Variables Values

1 Visual Analogue Scale ( VAS) Pain 4:10

2 Clinical Scoring Scale Functional Ability 68:80

3 Walking 10 Metres distance Time 38 secs

4 Step Length Distance 27 inches

5 Radiological Outcome Scores Residual Displacement NA

Table 6: Week Three assessment profile Assessment:

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All the assessed gross muscle power increased to 5/5, except knee flexors, hip abductors, flexors and extensors. Pain localized only to the anterior pelvic and above the Piriformis region of the right hip.

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S/N

Outcome Measure Outcome Variables Values

1 Visual Analogue Scale ( VAS) Pain 2:10

2 Clinical Scoring Scale Functional Ability 72:80

3 Walking 10 Metres distance Time 31 secs

4 Step Length Distance 27 inches

5 Radiological Outcome Scores Residual Displacement NA

Table 7: Week Four assessment profile

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Treatment evaluated and modified accordingly.

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S/N

Outcome Measure Outcome Variables Values

1 Visual Analogue Scale ( VAS) Pain 1:10

2 Clinical Scoring Scale Functional Ability 77:80

3 Walking 10 Metres distance Time 23 secs

4 Step Length Distance 27 inches

5 Radiological Outcome Scores Residual Displacement 4mm

Table 8: Week Five assessment profile Assessment

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Gross muscle power in all assessed muscle group are 5/5.Pain very mild and limited to above Piriformis region of right hip.

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Conclusion:

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Pubic symphysis rupture is an uncommon but often underestimated injury after vaginal delivery that can lead to significant chronic disability. Therefore, in case of peripartum suprapubic pain, it is important to consider a pubic symphyseal diastasis that requires interdisciplinary treatment.

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Conclusion:It is pertinent that clinicians should consider it when assessing patients in the ante-natal or post-natal period who complain of pain along the suprapubic, sacroiliac or thigh regions. Though the symptoms and clinical presentation are gross and may be incapacitating, conservative medical rehabilitation approaches are very effective.

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References

Aggarwal S, Bali K Krishnan V, Kumar V, Meena D, Sen RK (2011). Management outcomes in pubic diastasis: our experience with 19 patients. Journal of Orthopeadic and Surgical Research: Vol. 6. pp 21

Alessio P, Roberto B, Remo B, Dante S, Aldo G (2005). Post partum diastasis of the pubic symphysis: a case report. ACTA Bio Medical; 76; 49-52 Becker I, Woodley SJ, Stringer MD (2010). The adult human pubic symphysis: a systematic review. Journal of Anatomy. 217(5):475-487 Dhar S, Anderton JM. (1992). Rupture of the symphysis pubis during labour. Journal of Clinical Orthopeadics; 283: 252-257

Diagnosis of Pelvic Girdle Pain. Available @ www.acpwh.org.uk. Accessed on 6/2/2013 Dunbar RP. (2002). Puerperal diastasis of the public symphysis. A case report. Journal of Reproductive Medicine; 47: 581-3

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Dunbar RP, Ries AM (2002). “Puerperal diastasis of the pubic symphysis: a case report.” Journal of Reproductive Medicine for the Obstetrician and Gynecologist, vol. 47; no. 7, pp. 581–583

Exercise for Symphysis Pubis Dysfunction @www. mutusystem.com. Accessed on 20/6/2014 Gamble JG, Simmons SC. (1986). The Symphysis Pubis: Anatomic and Pathologic Considerations . Clinical Orthopaedics and Related Research Feb; No. 203; 261-272 Gräf C, Sellei RM, Schrading S, Bauerschlag DO (2014). Treatment of Parturition-Induced Rupture of Pubic Symphysis after Spontaneous Vaginal Delivery. Case Reports in Obstetrics and Gynecology Volume 2014, Article ID 485916, 3 Jain N, Sternberg LB (2005). “Symphyseal separation.” Obstetrics and Gynecology, vol. 105, no. 5, pp. 1229–1232

References

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ReferencesJoosoph J, Kwek, K (2007). “Symphysis pubis diastasis afternormal vaginal birth: a case report.” Annals of the Academy of Medicine Singapore, vol. 36; no. 1, pp. 83–85

Journal of Orthopaedic Surgery and Research (2011). Available @ www.josr-online.com. Accessed on 20/06/2014

Kelly O, Anne P, Gerald M (2002). Pubic symphysis separation. In: Foetal and Maternal Medicine Review (13th edition) pp 141-155. London, Butterworth-Heinemann

Kharrazi FD, Rodgers WB, Kennedy JG, Lhowe DW (1997). “Parturition-induced pelvic dislocation: a report of four cases.” Journal of Orthopaedic Trauma, vol. 11, no. 4, pp. 277–282

Larsen EC, Wilken-Jensen C, Hansen A, Jensen DV, Johansen S, Minck H, Wormslev M, Davidsen M, Hansen TM (1999). Symptom-Giving Pelvic Girdle Relaxation in Pregnancy: Prevalence and Risk Factors. Acta Obstetrics Gynecology Scandinavian 78(2):105-110

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Lebel DE, Levy A, Holcberg G, Sheiner E (2010). Symphysiolysis as an independent risk factor for cesarean delivery. Journal of Maternal-Foetal and Neonatal Medicine 23 (5): 417–420

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Surgery 71(2):304-6 Mulhall KJ, Khan Y, Ahmed A, O'Farrell D, Burke TE, Moloney M (2002). Diastasis of the pubic symphysis peculiar to horse riders: modern aspects of pelvic pommel injuries. British Journal of Sports Medicine 36(1):74-5 Musumeci R, Villa E (1994). Symphysis pubis separation during vaginal delivery with epidural anaesthesia. Journal of Regional Anaesthesia 19: 289-91

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Niederhauser, A, Magann EF, Mullin PM, Morrison JC (2008). “Resolution of infant shoulder dystocia with maternal spontaneous symphyseal separation: a case report.” Journal ofReproductive Medicine for the Obstetrician and Gynecologist, vol. 53, no. 1, pp. 62–64

Nouta KA, Rhee MV, Van Langelaan EJ ( 2011).“Symphysis rupture during partus.” Nederlands Tijdschrift voor Geneeskunde, vol. 155; p. A2802 Okafor UAC, Shokunbi TF (2009). Physiotherapy Management of Sub-acute Postpartum Diastasis of Pubic Symphysis: A case report. Journal of the Nigeria Society of Physiotherapy 17: 37-40 Omololu AB, Alonge TO, Salawu SA (2001). Spontaneus pubic symphysial diastasis following vaginal delivery. Africa Journal of Medical Science 30: 133-5

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Panditrao SA, Eknathrao BP, Popat GU, Ramkrishna MA (2005). Pubic Symphysial Diastasis During Normal Vaginal Delivery. Journal of Obstetrics India 55 No.4 July/August pgs:365-366

Rodrigo CG, Renato PC (2004). Nutrition pathways to the symphysis pubis. Journal Anatomy 204(3): 209–215

Rommens PM (1997). Internal fixation in postpartum symphysis pubis rupture: report of three cases. Journal of Orthopaedic Trauma 11(4):273-6

Samet T, Cem L, Memduh D, Suleyman EA, Recep H, Ilkhur C, Sinan B (2006). Pubic symphysis diastasis: Imaging and clinical features. European Journal of Radiology Extra 59(3): 127-129

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Scriven MW, Jones DA, McKnight L. (1995). The importance of pubic pain following childbirth: a clinical ultrasonographic study of diastasis of the pubic symphysis. Journal of Social Medicine 22: 48-52 Snow RE, Neubert, AG ( 1997). “Peripartum pubic symphysis separation: a case series and review of the literature.” Obstetrical and Gynecological Survey, vol. 52; no. 7, pp. 438–443 Symphysis Pubis Dysfunction. Available @ www.acpwh.org.uk. Accessed on 18/06/2014 Tsukahara S, Momohara S, Ikari K, Murakoshi K, Mochizuki T, Kawamura K, Kobayashi S, Nishimoto K, Okamoto H, Tomatsu T (2007): Disturbances of the symphysis pubis in rheumatoid arthritis: report of two cases. Mod Rheumatology 17(4):344-7 Wu WH, Meijer OG, Uegaki JM, Mens JH, van Dieën PI, Wuisman JM, Östgaard HC (2004). Pregnancy-related pelvic girdle pain (PPP), I: Terminology, clinical presentation, and prevalence. European Spine Journal 13, No. 7 / Nov  

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