A case presentation at Lagos University Teaching Hospital, Idi Araba Lagos, Nigeria in June 2014.

1. MANAGEMENT OF DIASTASIS PUBIC SYMPHYSIS: CASE
REPORT
By
Bakare, Akeem
1

2. Outline
2
Introduction
Epidemiology
Aetiology
Management
Prognosis
Case Study
Conclusion
Reference

3. 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).
3

4. Introduction:
Diagnosis can be confirmed rapidly by:
 Pelvic X-ray.
 Additionally, MRI serves to exclude soft tissue
injury (Graf et al, 2014).
4

5. Figure 1: Normal anatomical structure of a pelvic bone with intact pubic symphysis
5

6. 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).
6

7. Figure 2: X ray film of a diastasis pubic Symphysis of about 15mm
(Graf et al, 2014)
7

8. Figure 3: X ray film of a diastasis pubic Symphysis of about 60mm
(Graf et al, 2014)
8

9. 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.
9

10. Aetiology
This 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).
10

11. 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:
11

12. Table 1: Clinical scoring Scale
Patient ability score
Pain
Intense, continuous at rest 0 to 5
Intense with activity 10
Tolerable, but limits activity 15
With moderate activity, abolished by rest 20
Mild, intermittent, normal activity 25
Slight, occasional or no pain 30
Maximum 30
12

13. Sitting
Painful 0 to 4
Painful if prolonged or
awkward 6
Uncomfortable 8
Free 10
Maximum 10
13

14. Sexual Intercourse
Painful 0 to 1
Painful if prolonged or
awkward 2
Uncomfortable 3
Free 4
Maximum 4
14

15. Walking Aids
Bedridden or almost 0 to 2
Wheelchair 4
Two crutches 6
Two sticks 8
One stick 10
No sticks 12
Maximum 12
15

16. 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
16

17. 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
17

18. Functional outcome (total
score)
Excellent 78 to 80
Good 70 to 77
Fair 60 to 69
Poor <60
Aggarwal et al, 2011
18

19. Table 2: Radiological outcome scores
Outcome Residual displacement
Excellent 0-5 mm
Good 6-10 mm
Fair 11-15 mm
Poor >15 mm
19
Aggarwal et al, 2011

20. Management
Management includes:
 Conservative management
 Use of medications
 Surgery
20

21. Management:
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).
21

22. Rehabilitation
1. Bed rest
2. Deep breathing exercises
3. Isometric quadriceps contraction exercises
4. Ankle pump exercises
5. Cryotherapy
6. Soft tissue manipulation to the low back and hip
regions
7. Transcutaneous electrical nerve stimulation to the
low back and hip regions. (Okafor and Shokunbi,
2009).
22

23. Prognosis
Prognosis 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).
23

24. 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.
24

25. A Case Report:
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.
25

26. 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.
26

27. 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
27

28. 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.
28

29. Assessment revealed:
 Marked atrophy of the thigh muscles and gluteal
muscles
 Range of motion: PROM – Hip flexion/extension limited
with pain
oHip abduction/adduction limited because of
pain
oAROM – Not possible due to pain in all
ranges
 Strength: not assessed because of pain.
29

30. 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.
30

31. Radiological Investigation
 X-ray: Pelvic x ray revealed widening of
the pubic symphysis to 15mm: (normal >
7mm)
 Hip joint spaces are preserved.
31

32. Summary of assessment at first visit
Table 3:Week One assessment profile
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
32

33. Treatment given includes:
• Cryotherapy,
• TENS,
• Muscle setting for quadriceps, hamstrings and
gluteal muscles, ankle pump exercises,
• Soft tissue manipulation using voltaren emulgel,
33

34. 34
Treatment given includes:
• Application of pelvic belt support,
• Ambulation using walking frame,
• Counseling on bed rest,
• Positioning and movement of lower limbs
and Psychotherapy.

35. Treatment given includes:
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.
35

36. 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.
36

37. 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.
37

38. Table 4: Week Two assessment profile
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 inches
5 Radiological Outcome Scores Residual Displacement NA
Further assessment of muscle power was carried out because patient
could move limbs more actively with lesser pain.
38

39. Table 5: Gross Muscle Power chart for the lower limbs
Group of Muscle Tested Lower Limbs
Right Left
Hip Adductors 3:5 3:5
Hip Abductors 1:5 1:5
Hip Flexors 3:5 3:5
Hip Extensors 3:5 3:5
Knee Flexors 3:5 3:5
Knee Extensors 3:5 3:5
Ankle Dorsiflexors 5:5 5:5
Ankle Plantarflexors 5:5 5:5
Management:
Strengthening exercise program was included.
39

40. Table 6: Week Three assessment profile Assessment:
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
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.
40

41. Table 7: Week Four assessment profile
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
41
Treatment evaluated and modified accordingly.

42. Table 8: Week Five assessment profile Assessment
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
Gross muscle power in all assessed muscle group are 5/5.
Pain very mild and limited to above Piriformis region of right hip.
42

43. Conclusion:
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.
43

44. 44
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.

45. References
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