Osteomyelitis and osteitis of the pubic bones: two diseases under one mask

Symphysis pubis dysfunction (SPD) is described in the literature as a constellation of signs and symptoms of discomfort and pain in the groin region, including pelvic pain radiating to the upper thigh and perineum. The cause of this condition is the physiological weakening of the pelvic ligaments and increased mobility of the pubic symphysis during pregnancy. The severity of symptoms varies from mild discomfort to severe debilitating pain.

The literature also discusses the use of many other terms, such as pubosacroiliac arthropathy, pelvic dysfunction, pubic pain syndrome, sacroiliac joint syndrome, pelvic girdle pain, pelvic relaxation syndrome, and symphysis pubis dysfunction.

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Symbolism pubis dysfunction occurs when the joint becomes too relaxed, causing instability in the pelvic girdle. In severe cases of DLS, the pubic symphysis may rupture partially or completely. If the gap increases by more than 10 mm, it is called diastasis of the pubic symphysis.

Dysfunction of the symphysis pubis is a common and debilitating disease that affects women most often during or after pregnancy. It is accompanied by severe pain and can have a significant impact on quality of life and even lead to complications such as depression.

Clinically Relevant Anatomy

The pubic symphysis is located on the anterior side of the pelvis and is the anterior border of the perineum. The pubic bones form a cartilaginous joint in the midplane called the pubic symphysis. This joint holds the pubic bones together and provides stability during movement.

Together with the sacroiliac joints, the symphysis pubis forms a stable pelvic ring. There is very little mobility in this ring.

You can read more about the anatomy of the pelvic floor here.

The pubic symphysis is a cartilaginous connection of the pubic bones, between which there is a fibrocartilaginous interpubic disc. The pubic bones are connected to each other by four ligaments. The superior pubic ligament begins at the upper edge of the pubis and extends to the pubic tubercles. The arcuate ligaments of the pubis form the lower border of the pubic symphysis and are woven into the fibrocartilaginous interpubic disc. The stability of the joint is mainly provided by the strongest arcuate ligaments. Together, these four ligaments stabilize the joint and keep the articular surfaces from shifting and stretching.

The disc connects the articular surfaces of the two pubic bones. Each of these surfaces is covered with a thin layer of hyaline cartilage. The connection is not smooth; it contains papillary projections, depressions and protrusions.

In children, the disc is very small, the hyaline layer is very thick, but becomes thinner over time. In men, the disc is higher, smaller and narrower than in women. In its thickness, the disc has a slit-like cavity, which is normally 4-5 mm wide in women. In the last trimester of pregnancy, it increases by another 2-3 mm, which is necessary for the baby to pass through the birth canal. With dysfunction of the symphysis pubis, the joints become more relaxed, which leads to instability in the pelvic girdle. When the width of the cavity is equal to or exceeds 10 mm, diastasis of the pubic symphysis occurs.

What is a pelvis?4

“The pelvis refers to the lower abdomen in both men and women,” says Gillogly, a US gynecology professor. “An important function of the pelvic region is to protect the organs used for digestion and reproduction, although all of its functions are critical,” she says. “It protects the bladder, both the large and small intestines, and the male and female reproductive organs.” . Another key role is to support the hip joints.”

Epidemiology/Etiology

There are several theories about the origin of symphysis pubis dysfunction:

Aslan et al. They say that the etiology of the disease is unknown. During pregnancy, the load on the pelvis changes, ligaments and muscles weaken. This leads to spinopelvic instability, which manifests itself as DLS.

In early pregnancy, the corpus luteum produces large amounts of the hormone relaxin and progesterone. From the 12th week, this function is taken over by the placenta and the decidua of the uterus. Relaxin breaks down collagen in the sacroiliac joints, causing tissue softening. Progesterone has a similar effect. However, there is no correlation between relaxin levels and the degree of symphysis pubis dysfunction. A Norwegian study found that genetic predisposition to DLS may be caused by defects in relaxin secretion. It may seem that relaxation of the ligamentous apparatus directly indicates the presence of a hormonal basis for the disease. However, there is not enough data to support this theory.

The influence of stress and cortisol levels on pelvic pain.

Other factors leading to DLS include physically exhausting work during pregnancy, as well as pathological fatigue, poor posture and lack of exercise. Excess weight, multiple pregnancies, older pregnancies, a history of difficult labor, and shoulder dystocia may also play a role.

Effective adaptation of joints to a given load requires adequate joint compression and coordinated efforts of muscles and ligaments. This is the key to effective joint reactions to changing conditions. During pregnancy, ligaments and muscles become weaker and cannot perform their functions as they did before. As a result, the pelvic tilt changes, which leads to spinopelvic instability, most often manifested in dysfunction of the pubic symphysis.

In short, the causes of this instability are hormonal (influence of the hormone relaxin), metabolic (calcium metabolism), biomechanical (stress during pregnancy and exercise), underdeveloped muscles, body composition (weight), anatomical and genetic variations.

• The pelvic floor is made up of three layers of muscles. The superficial layer innervated by the pudendal nerve includes the bulbocavernosus muscle, the ischiocavernosus muscle, the superficial transverse perineal muscle, and the external rectal sphincter.
• The deep layer is the urogenital diaphragm, which is also innervated by the pudendal nerve. These include the urethral sphincter, constrictor bladder muscle, urethrovaginal sphincter and deep transverse perineal muscle.
• The pelvic diaphragm is made up of the following muscles: the levator ani muscle (pubococcygeus muscle, also known as pubo-prostatic, pubovaginal, pubo-anal, puborectal, iliococcygeus), coccygeus muscle, piriformis muscle and obturator internus muscle. These muscles are innervated by the sacral roots of the spinal cord (S3-S5).

The function of the pelvic floor muscles is to support the organs lying on it. The sphincters (anal and urinary) allow conscious control of the bowel and bladder. Thanks to this, we can consciously control the excretion of feces or fatus, as well as urine.

When contracted, the pelvic floor muscles are able to lift the internal organs and compress the openings of the sphincters of the vagina, anus and urethra. When the pelvic floor muscles relax, urine may leak and feces may be released uncontrollably. Pregnancy changes the functioning of these muscles, as well as their function.

The pelvic floor is a trampoline6

At the bottom of the pelvis is the pelvic floor. It can and should be strengthened with Kegel exercises to maintain its strength. The pelvic floor is like a mini trampoline made of hard muscle. Like a trampoline, the pelvic floor is flexible and can move up and down. It is also the surface for the pelvic organs: the bladder, uterus and intestines. It has openings for the vagina, urethra and anus.

Differential diagnosis

Leadbetter et al proposed a scoring system for diagnosing DLS and found 5 symptoms that may be significant in determining symphysis pubis dysfunction:

1. Pain in the pubic area while walking.
2. Pain occurs if the patient stands on one leg.
3. Pain occurs when climbing stairs.
4. Pain when turning over in bed.
5. History of injuries to the lumbosacral spine or pelvis.

Potential differential diagnosis symptoms should be excluded from the history. A physical examination and certain tests should be performed to rule out other diseases.

When carrying out differential diagnosis, the following diseases should be excluded: nerve compression (intervertebral disc damage), symptomatic lower back pain (lumbago and sciatica), pubic osteolysis, osteitis pubis, bone infection (osteomyelitis, tuberculosis, syphilis), genitourinary tract infection, pain in the round ligaments, femoral vein thrombosis and obstetric complications.

First aid

It is very important to know how to provide first aid for a fracture of the pubic bone, since with such injuries the speed of assistance is very important, which can become a determining factor in the recovery process.

Before the ambulance team arrives, the victim must be immobilized. If there are broken bone fragments, then immobilization will avoid injury to other organs. The patient should be placed on his back, and a cushion or other object should be placed under his legs in the knee area.

The victim can be given painkillers. It is necessary to monitor the pulse and heart rhythm and prevent the person from losing consciousness.

If the fracture is open, then the wound must be treated with disinfectants and covered with a piece of clean cloth to prevent bacteria from entering there. If there is significant blood loss, a tourniquet will have to be applied.

Diagnostics

As with any dysfunction, early diagnosis is important to prevent it from becoming a long-term problem. Diagnosis is usually made based on symptoms, but imaging is actually the only way to reliably diagnose symphysis pubis dysfunction. MRI, X-ray, CT, or ultrasound are used to confirm pubic symphysis dehiscence. Although radiography is not considered as a method of choice due to the danger of exposing the fetus to ionizing radiation. The most suitable method with excellent spatial resolution is MRI, which also avoids ionizing radiation.

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Other methods that can help in diagnosis and monitoring are transvaginal or transperinal ultrasound using high-resolution transducers. Using a method such as ultrasound, it is possible to measure the interpubic cavity. This may also be a consequence of diastasis of the pubic symphysis after childbirth.

The interpubic distance is mainly measured using electronic calipers. It is also important to know that ultrasound allows you to measure the interpubic space without ionizing radiation.

Outcome assessment

Articulus pubis dysfunction is described as a set of signs and symptoms of discomfort and pain in the pelvic area. There is still no single, 100% understanding of what exactly causes this condition. Therefore, it is not so easy to invent any other criteria other than pain and instability of the pelvic girdle, which could show the difference in the patient’s condition at the beginning and end of therapy.

However, there are studies on the development of a special scale for DLS. More studies related to outcome assessment are needed.

Inspection

It is important to conduct a physical examination to differentiate between other possible causes of symptoms, such as problems with the lumbar spine or a herniated disc. Here are some of the examination methods:

Palpation:

• Soreness of the pubic symphysis.
• Pain in the sacroiliac joints.
• Sacrotuberous ligament.
• Soreness of the following muscles: gluteal, iliopsoas, piriformis and paravertebral muscles.

Provocative tests (when they are positive, this helps establish DLS).

• FABER test

The examiner records one of the anterior superior iliac spines. The patient, in the supine position, flexes the hip and places the foot on the opposite knee joint, while the leg hangs passively outward. The test is considered positive if there is pain in the sacroiliac joint

• Active straight leg raise (ASLR)
• Pain in the symphysis when standing on one leg.
• Bilateral compression of the trochanter of the femur.

Range of motion may be reduced due to pain. Especially during lateral rotation and abduction.

The duck gait can occur due to weakness of the gluteus medius muscle, which normally functions as an abductor.

DLS can also be suspected if the patient experiences continuous pain during the following activities:

• Walking.
• Climbing the stairs.
• Turn over in bed.
• Standing on one leg.
• Getting up from a chair.

There are a number of tests for symphysis pain during pregnancy that have high sensitivity, specificity and reliability (Cohen's kappa coefficient > 0.40).

1. The patient lies down, the specialist palpates the entire anterior surface of the pubic symphysis. The test is positive if the result is pain that persists for more than 5 seconds after the end of palpation. (99% specificity, 60% sensitivity and 0.89 Cohen's kappa coefficient).
2. Trendelenburg's sign: When standing on one leg, the patient is unable to maintain a horizontal pelvic position because the opposite buttock descends (normally it should rise) (99% specificity, 60% sensitivity and 0.63 Cohen's kappa coefficient).
3. FABER test (see “palpation”) (specificity 99%, sensitivity 40% and Cohen’s kappa coefficient 0.54).

Links[edit]

This article incorporates public domain text from page 236 of the 20th edition

"Grey's Anatomy"
(1918).

1. "Definition: pubic body from the online medical dictionary". Retrieved October 18, 2008.
2. "crista pubica" in Dorland's Medical Dictionary
3. Bojsen-Möller, Finn (2000). Rörelseapparatens anatomi
   (in Swedish). Liber. p. 239. ISBN 91-47-04884-0.
4. "Definition: superior rami of the pubis from the online medical dictionary". Retrieved October 18, 2008.
5. ↑
   White, T.D. (August 9, 1989). "Analysis of suprapubic bone function in mammals using scaling theory". Journal of Theoretical Biology 139(3): 343–57. DOI: 10.1016/S0022-5193 (89) 80213-9. PMID 2615378.
6. Michael L. Power, Jay Shulkin. Evolution of the human placenta. P. 68–.
7. Frederick S. Szalai (May 11, 2006). Evolutionary history of marsupials and analysis of osteological characters. Cambridge University Press. P. 293–. ISBN 978-0-521-02592-8.
8. Seeley, H. G. (1888). " On the Classification of the Fossil Animals Commonly Called Dinosaurs."
   Proceedings of the Royal Society of London,
   43
   : 165-171.
9. Barsbold R (1979) Opisthopubic pelvis in carnivorous dinosaurs. Nature. 279, 792-793
10. Martin, A. J. (2006). Introduction to the Study of Dinosaurs. Second edition. Oxford, Blackwell Publishing. pp. 299-300. ISBN 1-4051-3413-5.

Drug treatment

During pregnancy:

• Paracetamol.
• Codeine-based drugs.
• Epidural using morphine/bupivacaine/fentanyl for 24-72 hours to break the cycle of pain and muscle spasm.

After childbirth:

• NSAIDs.
• Epidural using morphine/bupivacaine/fentanyl for 24-72 hours to break the cycle of pain and muscle spasm.

Other:

• If it is impossible to relieve the pain, go to the hospital.
• Injections of cortisol, chymotrypsin and lidocaine directly into the symphysis area.

Carefully monitor the effectiveness of measures taken and their side effects.

The female pelvis can change size8

Gillogly says that: "The female pelvis tends to be larger and wider than the male pelvis in order to accommodate the baby during pregnancy and allow for a natural birth." However, the female pelvis narrows with age, when there is no need for pregnancy. The changing shape of the pelvis is thought to be a key part of our evolutionary history, as it changed when we started walking upright.

Physical therapy

The following devices can be used as part of DLS therapy:

• Crutches with elbow support.
• Pelvic support devices: Lumbopelvic brace (the brace should be positioned strictly cephalad to the greater trochanter of the femur. The study does not recommend the use of a lumbopelvic brace as monotherapy because lumbar stability must be achieved through proper motor control and coordination ).
• Prescription pain relievers (use NSAIDs during pregnancy with caution).

Birth planning

• Women with DLS should give birth in an upright position with their legs slightly apart.
• The gap between the pubic bones should never exceed the maximum, so patients are advised to wear special tapes on both legs.
• During childbirth, you should not rest your feet on the midwife's thighs, use footrests, or use surgical forceps, as they can further stretch the ligaments.
• During labor and childbirth, the legs should be minimally apart.

Prevention

• Informing the patient: about her illness, as well as about the connection of the disease with the required and permissible load;
• about the need for rest;
• to reduce fear;
• to motivate the patient to actively participate in the treatment process;
• tips for everyday life (do household chores while sitting if possible, sleep with a pillow between your legs, keep your legs bent to get in/out of bed).

Exercises for hips

Aerobic exercise

• Moderate-intensity vigorous walking, defined as 64 - 76% of maximum heart rate, or 3 times a week for 25 minutes.
• Stretching exercises for the following muscles: hamstrings, inner and lateral thighs, quadriceps and back muscles. We should do it 3 times a week, 2 times a day. The duration of each exercise is from 10 to 20 seconds.

Strengthening exercises

Read about lower back pain and pelvic floor muscle incompetence here.

• The patients performed the following exercises: bending the torso forward, “cat”, diagonal twists, bending the upper body, raising the legs from the knee-elbow position (with parallel performance of Kegel exercises and control of pelvic tilt).
• The exercises are performed 3 times a week (2 sets of 3-5 repetitions on each side).
• The duration of each exercise is from 3 to 10 seconds.
• Pelvic muscle exercises [evidence level 1a]. (Exercises for instability of the lumbar spine)
• In early pregnancy: to reduce the risk of developing symphysis pubis dysfunction:
• Deep Abdominal Exercises: To increase core stability and prevent women from developing pelvic or back pain during pregnancy.
• You should start with a small number of repetitions, gradually increasing the time of muscle contraction.
• Particular attention should be paid to the transverse abdominis muscle, an important muscle whose contraction synergistically activates the pelvic diaphragm.

Stabilization exercises

Skeletal traction

Fractures of the pubic and ischial bones may require skeletal traction. The technique is also used for bilateral fractures and damage to the pelvic ring.

The procedure involves the use of a hammock, which is made of double dense fabric. The width of the structure is determined by the doctor. Round spacers for cords are sewn into the ends of the hammock, which are passed through blocks, which in turn are attached to the Balkan bed frame.

To monitor the healing process, several x-rays are taken. Skeletal traction lasts about 1.5 months, then adhesive traction is carried out for 1 month. Only after 3 months the patient will be allowed to get up and move, but only with crutches. Full load can be given only 4-6 months after injury.

Rehabilitation

The pubic bone after a fracture requires a long rehabilitation period for it to fully restore its functionality. It will require a lot of effort and patience from the patient. The rehabilitation course includes the following activities: massage, gymnastic exercises, physiotherapy. In addition, patients who have suffered this type of fracture are recommended to undergo sanatorium treatment and nutritional adjustments. All rehabilitation measures are complex therapy, and if the patient follows all the recommendations of doctors, then he has a great chance of full recovery.

Even at the stage of inpatient treatment, the patient must perform breathing exercises and general strengthening movements of the feet. Whether there was a fracture of the pubic bone without displacement or with it, first of all it is necessary to restore the psychological state of the victim while simultaneously relieving the pain syndrome. Measures are being taken to improve the overall tone of the whole body and lower extremities.

At later stages of rehabilitation, patients are recommended to visit the pool; it is recommended to do leg swings at home. Walking gives very good results. The duration of rehabilitation depends entirely on the individual characteristics of the victim’s body, as well as on his desire to quickly return to the normal rhythm of life.

Prevention

It is clear that with the fast pace of life, it is quite difficult to protect yourself from injuries and accidents, or to radically change your diet. However, if the stairs in the house are slippery, there are many of them, it is better to cover them with carpet and install handrails. If you have a vehicle, try to drive as carefully as possible and avoid road accidents.

When playing sports, do not forget about safety rules and do not allow heavy equipment to fall on your body. You should also be careful not to fall on any hard surface or sports equipment.

If possible, refuse to work at heights or in hazardous industries, in workplaces associated with vibration and contact with complex equipment, which can cause injury. It is clear that no one is immune from injury, but if this has already happened, then in no case should you lose heart, but find a real professional in medicine, trust him and maintain a positive attitude until the end of treatment and rehabilitation.

Classification of fractures and causes

Bone fractures are of open and closed type, unilateral and bilateral, rupture of connective tissues and crack of the pubic symphysis (symphysis). Injury can occur in various ways:

• sports injury - the pubic bone breaks due to overload and severe stretching;
• consequences of an unsuccessful fall and landing;
• road accident;
• due to strong compression of the pelvic area;
• during long and difficult labor;
• receiving a direct blow to the groin crotch.

Elderly people and women during menopause are most at risk of injury. Victims are diagnosed with a lack of calcium and collagen, which strengthens bone tissue. Due to a deficiency of these elements, the rami of the pubic bone are especially susceptible to fractures due to their very fragile structure.

With a severe deficiency of the vitamin complex, the bone structure can break even under minor loads.