What is the typical treatment for a pubic ramus fracture in a 90-year-old patient?

From the Guidelines

The typical treatment for a pubic ramus fracture in a 90-year-old patient is conservative management with pain control, limited weight-bearing, and gradual mobilization. This approach is based on the principle that surgery is usually reserved for cases with significant displacement or articular involvement, as suggested by the American College of Foot and Ankle Surgeons 1. In the context of a pubic ramus fracture, where the fracture fragments are often small, nonarticular, or minimally displaced, simple immobilization and conservative management are appropriate.

Key components of conservative management include:

• Pain management with acetaminophen (500-1000 mg every 6 hours, not exceeding 3000 mg daily) as the first-line medication, with careful use of NSAIDs like ibuprofen (400-600 mg three times daily) if not contraindicated by kidney function or other medical conditions
• Limited weight-bearing for 1-2 weeks, progressing from a walker to a cane as tolerated
• Physical therapy beginning within days of diagnosis, focusing on gentle exercises and transfers
• Fall prevention strategies, calcium (1200 mg daily) and vitamin D (800-1000 IU daily) supplementation, and consideration of osteoporosis treatment to prevent future fractures

Regular monitoring of pain levels, mobility progress, and potential complications like urinary retention or deep vein thrombosis is essential throughout recovery, which typically lasts 6-12 weeks. This conservative approach is preferred because surgery carries high risks in the elderly and most pubic ramus fractures heal well without surgical intervention 1.

From the Research

Treatment for Pubic Ramus Fracture in a 90-year-old Patient

The typical treatment for a pubic ramus fracture in a 90-year-old patient involves:

• Pain management and mobilization, as these fractures are typically classified as stable injuries 2
• However, pain-dependent immobilization may pose a serious hazard to patients with severe preexisting co-morbidities 2
• Conservative therapy is usually sufficient, but surgery can be indicated in cases with concomitant posterior ring fractures (cPRF) 3
• The principle aims in this patient population are satisfying pain management, early mobilisation, conservation of independence, and return to previous place of residence 4

Considerations for Treatment

Some key considerations for treatment include:

• Age is a predictive factor for 1-year mortality, with mortality increasing with higher age 2
• Concomitant posterior pelvic ring lesions are frequently associated with pubic rami fractures, making these injuries more unstable than generally assumed 4
• Patients with concomitant posterior ring fractures (cPRF) had a significant higher complication rate, but mortality and other morbidity outcomes did not statistically differ 3
• The strongest predictor for 1-year mortality was complications during admission and a dependent ambulatory status 3

Outcomes and Morbidity

Outcomes and morbidity for pubic ramus fractures in elderly patients include:

• Significant deterioration in ambulation and independency 3
• High rates of institutionalization at discharge (34%) and loss of independent mobility status (49%) 3
• One-year mortality rate of 23% 3
• Excess mortality, loss of independence, restricted mobility, and decreased quality of life compared to the normal population 5