Overview
Plating of the pubic symphysis through a Pfannenstiel approach is the standard technique for symphyseal disruption in pelvic ring injuries. In type C injuries, posterior fixation (e.g., iliosacral screws) is also needed.
Surgical Technique (Technique 61.8)
Positioning
Place the patient supine on a radiolucent table.
Keep the legs internally rotated, which helps the reduction.
Drape the whole pelvis, including the area distal to the pubic tubercles.
Approach
Make a Pfannenstiel incision 1–2 cm proximal to the pubic tubercles.
Split the rectus fascia longitudinally where the fibers decussate in the midline. Do not transect the rectus heads.
Place a malleable retractor in the space of Retzius to protect the bladder.
Elevate the rectus from the superior and anterior surfaces of the pubic tubercles.
Expose the symphysis by placing sharp Hohmann retractors deep to the rectus, over the rami just lateral to each tubercle.
Reduction
Place a Weber reduction clamp anteriorly on the pubic bodies. Seat the points at the same level on each pubic body, so that closing the clamp also corrects any sagittal-plane rotation of the symphysis.
Cranially displaced hemipelvis: Pull traction. If more control is needed, a Jungbluth clamp can be fixed with a 3.5 mm screw on the anterior surface on each side of the symphysis, which adds rotational control.
Fixation
Once reduction is satisfactory, apply a four- or six-hole curved reconstruction plate or a symphyseal plate to the superior surface of the symphysis.
Drill eccentrically to gain a little extra compression.
Confirm reduction and fixation on fluoroscopy.
In type C injuries, a second anterior plate can be added if needed.
Place a closed suction drain in the space of Retzius.
If a Pfannenstiel approach is not enough for ORIF of associated pubic rami fractures, use a modified anterior intrapelvic (AIP) approach or an ilioinguinal approach.
Postoperative Care (Pelvic Ring Fixation)
When comfort allows, start walking with crutches or a walker, with touch-down weight bearing on the injured side.
Highly unstable bilateral injuries: Bed-to-chair transfers and a wheelchair may be needed.
Depending on fracture pattern and bone quality, weight bearing usually starts 6–12 weeks after injury. A retrospective study (Marchand et al.) found no difference in implant failure between weight bearing at 6 weeks and at 12 weeks, though surgeon selection bias is likely.
VTE prophylaxis:
Without prophylaxis, up to 61% of patients with pelvic fractures develop DVT, and 29% develop proximal DVT. Pulmonary embolism caused 17% of preventable deaths in a review of nearly 13,000 trauma admissions.
Start chemoprophylaxis immediately after injury unless contraindicated, and resume it immediately after fixation.
PREVENT CLOT trial (12,211 patients): Aspirin 81 mg twice daily was equivalent to LMWH 30 mg twice daily in preventing death, DVT and PE, with similar bleeding and other serious adverse events, including in higher-risk subgroups (BMI > 40, bilateral non–weight bearing).
Reference
Beebe MJ. Fractures of the acetabulum and pelvis. In: Azar FM, Sawyer JR, Throckmorton TW, eds. Campbell's Operative Orthopaedics. 15th ed. Philadelphia: Elsevier; 2026. Chapter 61, Technique 61.8.