Surgical Discussion

Patient positioning:  The patient was positioned supine on a radiolucent operating table under general anesthesia. For intraoperative assessment, the lower extremities were placed in a "lotus" position to enhance visualization of pelvic ring injuries under fluoroscopy.

Anatomical surgical approach:  A combined Pfannenstiel and intrapelvic (modified Stoppa) approach was utilized. A transverse suprapubic skin incision was made approximately two fingerbreadths above the symphysis pubis. Dissection proceeded through the subcutaneous tissue and rectus sheath, with careful subperiosteal elevation of the rectus abdominis from the anterior pelvic ring. The retropubic space (Cave of Retzius) was developed to expose the symphysis pubis and superior pubic rami bilaterally. Intrapelvic exposure allowed direct visualization and reduction of the displaced right pubic ramus fracture and symphyseal diastasis. A pre-contoured plate was applied to the anterior ring using both direct and indirect reduction techniques.

Intraoperative fluoroscopy with AP and inlet views, as well as dynamic positioning of the lower extremities, was critical in fully delineating the extent of injury, which had been underestimated on preoperative imaging due to binder application. The excessively curved morphology of the right pubic ramus precluded safe or effective straight screw fixation; therefore, ORIF with a contoured plate was performed using intrapelvic exposure for optimal fit and stability. Indirect closed reduction of the SI joints was accepted, followed by percutaneous trans-sacral screw fixation under fluoroscopic guidance. This case highlights the necessity of thorough intraoperative assessment for occult or underestimated injury patterns in complex pelvic trauma, particularly when initial imaging is performed with a pelvic binder in situ.

Postoperative protocol:   Early mobilization with protected weight bearing as tolerated using crutches or walker for 8–12 weeks. Thromboprophylaxis initiated postoperatively. Hip and knee range-of-motion exercises commenced on postoperative day one. Progression to full weight bearing guided by radiographic evidence of healing at 10–12 weeks.

Follow up:   Not specified

Orthopaedic implants used:   Pre-contoured anterior pelvic reconstruction plate; percutaneous trans-sacral cannulated screws