Is a left inferior pubic ramus fracture with minimal displacement and comminution, along with a superior (sup) ramus fracture, a candidate for non-operative management?

Management of Left Inferior Pubic Ramus Fracture with Minimal Displacement

A left inferior pubic ramus fracture with minimal displacement and comminution, along with a superior ramus fracture, should be managed non-operatively with early functional rehabilitation and weight bearing as tolerated.

Classification and Stability Assessment

Pelvic fractures are classified based on stability and fracture pattern:

• The described fracture pattern (minimally displaced inferior and superior pubic rami fractures) is consistent with a Lateral Compression type 1 (LC-I) injury according to the Young & Burgess classification system 1
• LC-I injuries are considered stable fracture patterns that do not disrupt the posterior pelvic ring elements 1
• Stable fracture patterns like LC-I injuries do not require surgical fixation 1

Management Approach

Initial Assessment

• Ensure hemodynamic stability (blood pressure >90 mmHg, heart rate <100 bpm) 1
• Exclude other sources of hemorrhage with E-FAST and chest X-ray if hemodynamically unstable 1
• Obtain pelvic X-ray to identify fracture pattern 1
• Consider CT scan with 3D reconstruction for better characterization of the fracture pattern in stable patients 1

Treatment Plan

1. Non-operative management is indicated for:

   • Stable fracture patterns (LC-I injuries) 1
   • Minimally displaced pubic rami fractures 1
   • Absence of posterior pelvic ring instability 1

2. Mobilization protocol:

   • Early functional rehabilitation 1
   • Weight bearing as tolerated 1
   • Appropriate analgesia to facilitate mobilization

3. Monitoring considerations:

   • Watch for signs of hemodynamic instability in the first 48-72 hours, as delayed bleeding can occur even in stable pubic rami fractures 2
   • Monitor hemoglobin levels, vital signs, and pain control

Special Considerations

When to Consider Surgical Intervention

Surgical fixation would only be indicated if:

• Evidence of posterior pelvic ring instability (not present in this case) 1
• Rotationally unstable fracture patterns (APC-II/III, LC-II/III) 1
• Vertically unstable fracture patterns (VS, CM) 1
• Progressive displacement during follow-up 3

Potential Complications to Monitor

• Delayed hemorrhage from pelvic vessels (can occur up to 48 hours post-injury) 2
• Progressive displacement during mobilization 3
• Chronic pain and functional limitations 4, 5

Special Caution for Patients with Hip Arthroplasty

• In patients with ipsilateral total hip replacement, thorough investigation including CT scan is recommended to exclude acetabular extension before mobilization 4
• This is not applicable to the current case but important to note for similar presentations

Follow-up Recommendations

• Clinical follow-up within 1-2 weeks
• Radiographic follow-up to ensure maintenance of alignment
• Progressive physical therapy to restore function and prevent deconditioning

The biomechanical evidence suggests that transverse-type pubic rami fractures (as opposed to oblique-type) have less potential for displacement over time, which may further support non-operative management in this case 3.